CombiGuide Rx

Doctor and Patient Info
Partner
Date

MonthDayYear
Date
Doctor Name*
E-mail*
Phone Number*
Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Name*
Patient Age*
Treatment Info
Arch*
Select Case Type*
Select Case Type*
Back-Up Denture*
Surgery Information
Implant Brand*
Guided Kit*
Are you doing photogrammetry or grammetry?*
Are you using OptiSplint?

YesNo
Grammetry OptiSplint

Add Grammetry Kit for 4 implants - $295Add Grammetry Kit for 5 implants - $375Add Grammetry Kit for 6 implants - $445
Are you incorporating the 1 Scan Technique?*
Stacking Pins (required for LITE cases)*
Tooth Set-Up*
Records needed subject to selection

CBCTSTLs of dentate patientPhotos if smile zone is in question
Type of Restoration
Impressions / Models*
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.
SurgiMat Implant Info and Organizer*
Chairside Support
CombiGuide Timeline
- 5 business days - Record analysis and case workup
- 2/3 business days - Schedule and attend live planning meeting
- 6 business days - Fabrication
- 1-2 business days - Shipping
Additional Notes
Master Surgical Agreement
Master Surgical Agreement Consent*

I agree to the Master Surgical Guide Agreement per the text below
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Once you click Submit Rx and go to Records Upload a pdf copy of CombiGuide Rx is 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:

Doctor and Patient Info

Treatment Info

Surgery Information

Master Surgical Agreement

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