Clone of CombiGuide Rx

Doctor and Patient Info
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doctor Name
E-mail
Phone Number
Format: (000)-000-0000.
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?
Grammetry OptiSplint
Stacking Pins (required for LITE cases)
Tooth Set-Up
Records needed subject to selection
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
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
Master Surgical Agreement
Master Surgical Agreement Consent
Shipping Charge
Total
Should be Empty:

Doctor and Patient Info

Treatment Info

Surgery Information

Patient Records Upload

Master Surgical Agreement