CHROME Digital Rx

CHROME Digital Rx
Doctor and Patient Info
Partner
Date

MonthDayYear
Date
Are you the..*

Placing
Placing Doctor Name*
Placing Doctor Email*
Placing Doctor Phone Number*
Placing Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Placing Doctor Specialty*

Restorative
Restorative Doctor Name*
Restorative Doctor E-mail*
Restorative Doctor Phone Number*
Is Address same as above?

YesNo
Restorative Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Restorative Doctor Specialty*
Shipping Address*
Which account should this be assigned to?*

Both
Doctor Name*
Doctor E-mail*
Doctor Phone Number*
Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Info
CHROME Experience*
Patient Name*
Patient Age*
Treatment Info

Case Info
Select Case Type*
Single Arch Type*
Specialty Implants (Maxilla Only)
Pterygoid Implant Brand*
Pterygoid Guided Kit*
Nasalis Implant Brand*
Nasalis Guided Kit*
Zygomatic Implant Brand*
Zygomatic Guided Kit*

Single Arch
Choose the CHROME product*
CHROME package options*
Full package selection results in 8-10% savings vs. al a carte
- CHROME Surgical Package includes model work, articulation, record analysis, articulation, virtual tooth set-up, implant and bone reduction planning, live online planning session, day of surgery CHROME package with immediate load provisional and RAPID appliance.
- CHROME Full Package includes ALL ITEMS from Surgical Package, plus iJIG, Printed Try-In, final restoration, miniComfort guard.
For more information CHROME click here.
CHROME Natural package options*
Full package selection results in 8-10% savings vs. al a carte
- CHROME Natural Surgical Package includes model work, articulation, record analysis, articulation, virtual tooth set-up, implant and bone reduction planning, live online planning session, day of surgery CHROME package with long term provisional and RAPID appliance.
- CHROME Natural Full Package includes ALL ITEMS from Surgical Package, plus iJIG, long-term Printed Try-In, final restoration, miniComfort guard.
For more information on CHROME Natural click here.
Include the optional metal scallop guide?*
Full scalloped guide for labial reduction guidance and socket shaping or labial reduction guide only.
GuidedSMILE LITE options*
Single arch, describe the opposing condition*
Do you require a JC Try-In?*

Yes, fabricate a JC Try-In to ensure the bite is ideal (CTJC). The fabrication of a JC Try-in will add 2 additional weeks to the timeline.
Single arch additional options

Fabricate a JC Try-In to ensure the bite is ideal? (CTJC) - $140
More info on the JC Try-in
Prosthetic design*
Additional costs can be incurred depending on the choice made
Not compatible with C2F: Astra TX, Astra EV, Ankylos, BHI, Bicon, Camlog, ConeLog , Frialit, InnoBioSurg, MIS (OEM Screws), Biotech, Neoss, Paltop, Xive

Note: C2F small hole technology will add to the cost of the first case $619. This example includes 6 x C2F Assemblies ($94 ea), 1 x Drill ($10), 1 C2F model ($45). Subsequent cases can be only $19/implant extra for C2F analogs and the $45 C2F model.

ROE recommends chairside assistance for the first C2F case to teach this new conversion process.

If you are unaware of the power of C2F please watch the C2F educational videos https://www.roedentallab.com/C2F.

Dual Arch
Maxillary
Choose the CHROME product*
CHROME package options*
Full package selection results in 8-10% savings vs. al a carte
- CHROME Surgical Package includes model work, articulation, record analysis, articulation, virtual tooth set-up, implant and bone reduction planning, live online planning session, day of surgery CHROME package with immediate load provisional and RAPID appliance.
- CHROME Full Package includes ALL ITEMS from Surgical Package, plus iJIG, Printed Try-In, final restoration, miniComfort guard.
For more information CHROME click here.
CHROME Natural package options*
Full package selection results in 8-10% savings vs. al a carte
- CHROME Natural Surgical Package includes model work, articulation, record analysis, articulation, virtual tooth set-up, implant and bone reduction planning, live online planning session, day of surgery CHROME package with long term provisional and RAPID appliance.
- CHROME Natural Full Package includes ALL ITEMS from Surgical Package, plus iJIG, long-term Printed Try-In, final restoration, miniComfort guard.
For more information on CHROME Natural click here.
Include the optional metal scallop guide?*
Full scalloped guide for labial reduction guidance and socket shaping or labial reduction guide only.
GuidedSMILE LITE options*
Maxillary Occlusion*
Prosthetic design*
Additional costs can be incurred depending on the choice made
Not compatible with C2F: Astra TX, Astra EV, Ankylos, BHI, Bicon, Camlog, ConeLog , Frialit, InnoBioSurg, MIS (OEM Screws), Biotech, Neoss, Paltop, Xive

Note: C2F small hole technology will add to the cost of the first case $619. This example includes 6 x C2F Assemblies ($94 ea), 1 x Drill ($10), 1 C2F model ($45). Subsequent cases can be only $19/implant extra for C2F analogs and the $45 C2F model.

ROE recommends chairside assistance for the first C2F case to teach this new conversion process.

If you are unaware of the power of C2F please watch the C2F educational videos https://www.roedentallab.com/C2F.
Mandibular
Choose the CHROME product*
CHROME package options*
Full package selection results in 8-10% savings vs. al a carte
- CHROME Surgical Package includes model work, articulation, record analysis, articulation, virtual tooth set-up, implant and bone reduction planning, live online planning session, day of surgery CHROME package with immediate load provisional and RAPID appliance.
- CHROME Full Package includes ALL ITEMS from Surgical Package, plus iJIG, Printed Try-In, final restoration, miniComfort guard.
For more information CHROME click here.
CHROME Natural package options*
Full package selection results in 8-10% savings vs. al a carte
- CHROME Natural Surgical Package includes model work, articulation, record analysis, articulation, virtual tooth set-up, implant and bone reduction planning, live online planning session, day of surgery CHROME package with long term provisional and RAPID appliance.
- CHROME Natural Full Package includes ALL ITEMS from Surgical Package, plus iJIG, long-term Printed Try-In, final restoration, miniComfort guard.
For more information on CHROME Natural click here.
Include the optional metal scallop guide?*
Full scalloped guide for labial reduction guidance and socket shaping or labial reduction guide only.
GuidedSMILE LITE options*
Mandibular Occlusion*
Prosthetic design*
Additional costs can be incurred depending on the choice made
Not compatible with C2F: Astra TX, Astra EV, Ankylos, BHI, Bicon, Camlog, ConeLog , Frialit, InnoBioSurg, MIS (OEM Screws), Biotech, Neoss, Paltop, Xive

Note: C2F small hole technology will add to the cost of the first case $619. This example includes 6 x C2F Assemblies ($94 ea), 1 x Drill ($10), 1 C2F model ($45). Subsequent cases can be only $19/implant extra for C2F analogs and the $45 C2F model.

ROE recommends chairside assistance for the first C2F case to teach this new conversion process.

If you are unaware of the power of C2F please watch the C2F educational videos https://www.roedentallab.com/C2F.

Mobile Teeth*
Identify Mobile Teeth Number(s)
Provisional Tissue Shade*
Provisional Tooth Shade*
Patient Records & Case Design
Please use our checklists to help with record collection. They are based on how patient presents - CHROME Patient Record Checklists
Impressions submitted*
Other IOS Scanner*
Photographs*
Would you like a Smile Simulation by PreVu?*
Smile design options for full package*
Smile design options for surgical package*
Smile design notes
VDO Change*
Adjust VDO in mm's*
Additional VDO Option

Yes, fabricate a JC Try-In to ensure the bite is ideal (CTJC) - $140
Labial injection points for prosthetic pick-up
ROE will create holes from the labial and buccal that allow the pick-up material to be injected with the prosthetic seated on the Carrier Guide with the patient biting in occlusion.
Surgical bite included*
Surgery Information
Implant Brand*
Several implant brands require OEM parts for some or all of the final restorative steps. The price of these OEM parts differ per brand and will raise the cost - call for pricing if needed. Full package Rx cost estimates DO NOT include the cost for OEM parts.
Other*
Implant line (specific name of the implant)
Guided Kit*
Other*
Chairside Support*
Fixation kit (pins and drills)*
CHROME uses specific, custom designed fixation drills and pins. The standard kit includes one drill and four pins. This is determined after the planning meeting and the pins and drills will be sent with the case, if the doctor does not already have a set. It is recommended to purchase a full kit when starting the first case. The drills and pins are reusable for multiple surgeries. Cost subject to change based on case details.
Included GuidedSMILE LITE Fixation Pins*
Stellar DC acrylic pink kit (PCK4)
Price: $98.00
Stellar DC acrylic white kit (PCK5)
Price: $110.00
VOCO Quick-Up self cure kit (PCK1)
Price: $230.00
Maxillary Arch Denture*
Whether you need a back-up or are restoring the opposing arch, ROE offers three types of CHROME dentures - 1) economy back-up for the day of surgery (not to be connected to implants), 2) a standard denture that can be converted to implants later, and 3) a Premium version with cards of traditional teeth. All are very esthetic. They just differ in strength to meet your needs.
Mandibular Arch Denture*
Acknowledgment*

I recognize that my impressions need to include full palate and all land areas.
What is the final restorative material?*
Schedule surgery after the online meeting*

I AGREE
CHROME Timeline
- 5 business days - Record analysis and case workup
- 2/3 business days - Schedule and attend live planning meeting
- 10 business days - Fabrication
- 2 business days - Shipping
Additional Notes

Master Surgical Agreement
Master Surgical Agreement*

I agree to the Master Surgical Agreement per the text below

Total
Important information: CHROME prepaid packages are intended to cover all costs, but are limited in scope. OEM parts during the restorative phase will increase the cost of all cases, and several implant brands require OEM parts. Please contact us if an estimate is needed. Full package Rx cost estimates DO NOT include the cost for OEM parts.
Total
Once you click Submit Rx and go to Records Upload a pdf copy of CHROME Rx will be emailed to you – if you do not see this email appear immediately please check your spam/junk folder.

On the next page you will be prompted to upload patient files and complete the Rx process.
Should be Empty:

CHROME Digital Rx

Doctor and Patient Info

Split Fee Arrangement

Treatment Info

Maxillary

Mandibular

Patient Records & Case Design

Surgery Information