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.
Office Phone Number
Please enter a valid phone number.
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*

Implant Path & Position Video Report Only (For patient consultation)Video Report + Surgery Report + Guide Design (Including Mesh file for printing guide template)Video Report + Guide Design + Surgery Report + Guide TemplateFull arch guide package : 1 x Radiographic Guide, Video Report, Surgical Report, Guide Template
Will There Be Extractions? (If Yes, Please Indicate In The Case Description)*

YesNo
Will You Be Sending Digital Files, Physical Models, Or Both?

Digital Files Only (All My Files Are Here On This Form)Physical Models And CBCT Physical DeviceFiles will be sent through another portal (specify in the Case Description)
Implant Brand*
Implant Platform*
I Want Fixation Pins/Screws

I Want Pins/ScrewsNo fixation
Sleeves

Pilot Drill OnlyFully Guided drilling sleeves
Pins/Screws

I have some, don't order for me.I don't have them, please order for me and ship them with my guide.
Extras

Printed JawReline TemporaryMilled Immediate Temporary - Full Arch
Surgical Planning Consultation

No. I Will Wait for Design Approval Sent By Email.15 Minute Clinical Review Call (Extra $).
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.
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