Clone of GuidedSMILE Digital Rx

Doctor and Patient Info
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you the..
- Placing Doctor Name
- Placing Doctor Email
- Placing Doctor Phone Number
  Format: (000)-000-0000.
- Placing Doctor Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Placing Doctor Specialty
- Restorative Doctor Name
- Restorative Doctor E-mail
- Restorative Doctor Phone Number
  Format: (000)-000-0000.
- Is Address same as above?
- 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?
- Doctor Name
- Doctor E-mail
- Doctor Phone Number
  Format: (000)-000-0000.
- Doctor Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Split Fee Arrangement
- - Surgeon is typically responsible for the Planning, Surgical Guides, the Prosthetic and RAPID Guide =
    42% of the total package.
  - Restorative Doctor is typically responsible for the back-up denture and the final prosthesis =
    58% of the total package.
  Amend the pre-selections where necessary. Add any additional info in the notes field.
- Tooth & Implant Planning
- Surgical Guides
- Prosthetic & RAPID Prosthetics
- Backup Denture
- Final Prosthesis
- Optional: Stellar/VOCO acrylic
- Optional: Fixation Kit(s)
- Optional: Additional denture(s)
- Optional: JC Try-in(s)
- Split Fee Notes
- CHROME Experience
- Patient Name
- Patient Age
- Treatment 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
- 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.
- 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.
- 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?
- Single arch additional options
- 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.
  
  GuidedSMILE recommends chairside assistance for the first C2F case to teach this new conversion process.
- 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.
  
  GuidedSMILE recommends chairside assistance for the first C2F case to teach this new conversion process.
- 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.
  
  GuidedSMILE recommends chairside assistance for the first C2F case to teach this new conversion process.
- 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
- Labial injection points for prosthetic pick-up
  GuidedSMILE 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 Info
- 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: $100
- 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, GuidedSMILE 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
- What is the final restorative material?
- Schedule surgery after the online meeting
- 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
- 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
- Patient Records Upload
- Important final steps:
  - Place all your files (i.e. dicom< files, photos and other patient records, etc) into ONE folder and zip that folder (How to zip a folder: Windows | Apple)
  - Drag and drop/select your patient folder in the box below
  - Complete the form and click Submit
  - MAX of 1GB PER FILE
  Please note: Individual dicom files cannot be uploaded – they must be zipped into a folder before uploading.
- Records Upload
  
  Cancelof
- Should be Empty:

Doctor and Patient Info

Split Fee Arrangement

Treatment Info

Maxillary

Mandibular

Patient Records & Case Design

Surgery Info

Patient Records Upload