Scan Submission Form

Please answer the following*

	Yes	No
Is there any prior bone grafting?
Was an IBUR Imaging Aligner used for this case?

Instructions

Surgial Plan Preparation Instructions
Maxilla*

YesNo
Type of Guide*

Partial Edentulous GuideEdentulous Guide (for Overlay Denture)Edentulous Guide (for Fixed Restoration)
Area of Interest*
Teeth #s / # of implant
Mandible*

YesNo
Type of Guide*

Partial Edentulous GuideEdentulous Guide (for Overlay Denture)Edentulous Guide (for Fixed Restoration)
Area of Interest*
Teeth #s / # of implant
Preferred Implant Brand & Product Line
Company / Implant name (i.e. Nobel / NobelActive)
Are you ordering Diagnostic Wax-up?

Yes - Manual Diagnostic Wax-upYes - Digital Diagnostic Wax-up for planning purpose onlyNo
Teeth #s for wax-up
* Digital dental wax-up is free of charge up to 2 missing teeth next to each other on each side of the jaw.

For larger cases, we stronly recommend sending us a study model or ordering diagnostic wax-up. If you are ordering diagnostic wax-ups, please send us a dental cast, opposing model and bite registration.
Other special instructions (if any)
Is an imaging center submitting scan data for this patinet?*

YesNo
Name of the Imaging Center
Teeth #s / # of implant
Submitted Scan Data (Please check all applicable items.)

CBCT Scan of a patient (Multi-file DICOM files)CBCT Scan of an scan appliance (Multi-file DICOM files)Digital Dental Impression - STL file(s)Blue Sky Plan File
Coupon Code (if any)
Should be Empty:

Data Process / Surgical Plan Preparation Order Form