Clone of CombiGuide Rx

Doctor and Patient Info
ROE File ID
Partner
Date

MonthDayYear
Date
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 Next Steps
- 3 business days - Case is ready for online meeting
- Schedule your meeting on Page 3 of this form - to book sooner call the CT Department
- Cases are fabricated in 5 business days with overnight shipping
Additional Notes
Master Surgical Agreement
Master Surgical Agreement Consent
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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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