Surgical Guide Order Form

Surgical Guide Order Form

Prime Dental Solutions
Doctor’s Name

First NameLast Name
Doctor’s E-mail
example@example.com
Doctor’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Office E-mail
example@example.com
Patient’s Name

First NameLast Name
Deadline To Receive The Guide Or Scheduled Surgery Date

DayMonthYear
Date
Shipping Address (First Time Customers Only)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Address (If Different From The Shipping Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Accounting - Person Of Contact

First NameLast Name
Accounting E-mail
example@example.com
Case Description (e.g. Teeth numbers)
What Should We Know About This Case?
Products - Surgical Planning and Guide
Will There Be Extractions? (If Yes, Please Indicate In The Case Description)
Will You Be Sending Digital Files, Physical Models, Or Both?
Implant Brand
Implant Platform
I Want Fixation Pins/Screws
Sleeves
Pins/Screws
Extras
Surgical Planning Consultation
Upload The Patient's Zipped DICOM Folder (.ZIP, .RAR or .DCM (If 1 File Only))If You Are Having Issues, You Can Also Use WeTransfer And Send To) digitallabpds@gmail.com

All Dicom Files Of The Same Object Must Be Inside A Single Folder, Please. **** PLEASE CHECK THE QUALITY OF YOUR IMAGES BEFORE SENDING. BAD QUALITY FILES REQUIRING YOU TO RETAKE THE CBCT MIGHT BY SUBJECT TO REMAKE FEES.
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Upload The Patient's STL Files

If Your File Exceeds 1 GB, Please Split Your File Into Smaller Pieces Of 1 GB Or Less.
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Upload The Zipped DICOM Folder Of Denture With Markers - ONLY FOR DUAL SCAN PROTOCOL

All Dicom Files Of The Same Object Must Be Inside A Single Folder, Please. **** PLEASE CHECK THE QUALITY OF YOUR IMAGES BEFORE SENDING. BAD QUALITY FILES REQUIRING YOU TO RETAKE THE CBCT MIGHT BY SUBJECT TO REMAKE FEES.
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Upload Your Pictures In JPEG Format.

For Full Arch Cases, Send The Following 3 Pictures: Full Face Smile, Full Face Retracted, Close Up Smile Retracted.
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Please kindly note that payment is due upon delivery. our account team will email you with a payment link please arrange the payment by credit card so that your guide can be dispatched.
Signature
License Number:
Should be Empty: