Surgical Guide Case Submission
Doctor Information
Doctor Name
First Name
Last Name
Practice Name:
*
Email for Confirmation Receipt:
*
example@example.com
Email Confirmation for Additional Team Members
example@example.com
Patient Information
Patient Name:
*
Patient DOB:
*
-
Month
-
Day
Year
Date
Is the surgery scheduled?
*
Yes
No
Day of Surgery:
-
Month
-
Day
Year
Date
Patient Gender
Male
Female
Other
Case Information
What is the Planned Prosthesis?
*
What services are request for this case?
*
Planning only (Integrity Dental Services plans the case and provides files for printing)
Printing only (Integrity Dental Services receives plans and prints the case for delivery)
Full Service (Integrity Dental Services plans and prints the case for delivery)
Indication Selection
*
Maxilla
Mandible
Dual
Please indicate the type of guide requested
*
Pilot
Fully Guided
Stackable
Status of Patient
Edentulous
Dentate
Implant System
*
Implant Manufacturer
*
Please indicate type of surgical kit for this guided system.
*
PMMA Shade
A1
A2
B1
B2
BL
Other
Other PMMA Shade
Additional Lab Instructions:
Additional Files: Like Case Photos, Digital Impression Scans, and Supporting Documents if Necessary (dicom and stl files are required for production and planning of all surgical guides)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
License Number
Signature
*
Other Services
Printed skull for zygomatic planning (additional fee)
File Upload (dicom)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Print
Submit
Should be Empty: