Doctor Name
*
Primary Email To Send Files
*
Phone Number
*
Secondary Email To Send Files
*
Turnaround Time
*
Please Select
1hr
24hr
Arch
*
Please Select
Upper Arch
Lower Arch
Tooth Numbers
*
Osteotomy Guide Specifics
*
Please Select
Guided kit will be used
Piot guide only (provide length and width in Notes field)
Implant Brand
*
Please Select
3i T3 Zimvie
Adin Closefit
Adin Touareg
Astra TX (requires OEM parts)
Astra EV (requires OEM parts)
Ankylos
BHI
Bicon (requires OEM parts)
BioHorizons Fusion
BioHorizons Pro Conical
BioHorizons Tapered Internal
BioHorizons Tapered Plus
BioHorizons Tapered Pro
BlueSkyBio
Camlog (requires OEM parts)
ConeLog
Dentis
DIO
Ditron Molecular
Ditron Precision
Frialit (requires OEM parts)
Hahn
Hiossen
Implant Direct
InnoBioSurg (requires OEM parts)
Keystone Genesis TriLobe
Keystone Genesis Active
Keystone Prima Plus
Keystone Prima
MIS SEVEN (requires OEM parts)
MIS C1 XD (requires OEM parts)
Megagen AnyRidge
Megagen Blue Diamond
NeoBiotech (requires OEM parts)
NeoDent Helix
NeoDent GM
Neodent Drive
Neoss (requires OEM parts)
Nobel Biocare Active
Nobel Biocare N1
Nobel Biocare Parallel
Nobel Biocare Replace
Noris Medical
OCO Biomedical
Paltop (requires OEM parts)
Ritter
SIN
Southern Internal Tapered
Southern DC CO-A CoAxis
Southern Tri-Nex
Southern Other
Straumann BLT
Straumann BLX
Straumann TLX
Tag
Thommen
Xive (requires OEM parts)
Zimvie TSV
Zimvie TSX
Zimvie Trebecular
Zimvie T3 Pro Tapered
Other, indicate in Notes
Guided Kit
*
Please Select
3i Zimvie Navigator Parallel
3i Zimvie Navigator Tapered
Anatomage Kit
ADIN Guided
Astra EV
Astra Prime Taper
Astra TX
BioHorizons - Original Keyed CGS3000
BioHorizons - Pro Surgical System - PRO4000
BioHorizons - Pro Surgical System - PRO5000
BlueSkyBio Direct Cut - Need Handpiece Brand - must type notes
BlueSkyBio Keyless Guided
CamLog / Conelog Screw-Line
CamLog / Conelog Progressive-Line
Dentis SQ Guide Kit
Dentium
Hahn Guided Kit
Hiossen Osstem Guided (keys)
Hiossen One Guide (keyless)
Implant Direct - Standard Guided Kit (DLC Original Keys)
Implant Direct - DIRECTRguide GBR New Keyless Kit (New 2023)
Implant Vision
In2Guide Kit
iTools
Keystone Genesis Active
Keystone Genesis Kit
Keystone Prima Kit
Keystone Prima Plus Kit
Materialize Implant System
MegaGen R2 Guide
MIS - Guided
NeoDent Easyguide Kit New
NeoDent GM Keyed Kit
Neoss
Nobel Guided Kit
Noris Medical EZGuide Guided Set
Noris Premium Zygomatic Surgical Set
Paltop
Pilot Only (any implant system)
Ritter - must send physical kit to ROE for QC
SIN Guided Kit
Southern SIREAL
Straumann Kit - Locking Keys
Straumann Kit - Non-Locking Keys
Straumann Kit - Tissue Level Kit
SurgiKor - Scan Implant Guide
Sweden & Martina SpA
Thommen Guided
Tru Abutment Kit
Zimvie 3i Navigator Parallel
Zimvie 3i Navigator Tapered
Zimvie Z3D New Kit 2022
Zimmer Guided Kit - OLD Spoon Kit
Other - enter information into Notes
Sleeve Option
*
Please Select
Design with sleeves (doctor has ordered the sleeves from the implant company)
Design with no sleeves
Digital Impressions and CBCT
*
I will be submitting them with this Rx
Notes
Patient Files
*
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