One Guide Order Form

Service Fee & Conditions* This field is required.The cost of the planning fee is $150. However the planning fee will be waived if the case is confirmed and the surgical guide template is made. 1) The planning fee will be charged if you would like to drop the case after receiving the surgical planning report. 2) The planning fee will be charged if there is no response or no confirmation within 60 days of receiving the surgical planning report.

Clinic Name* This field is required.

Doctor's Name* This field is required.

First Name

Last Name

Email Address* This field is required.(Surgical report will be sent to this email address)

example@example.com

Sales Representative Name* This field is required.

Order Product

Shipping Items for Order * This field is required.

CT Data

Order Sheet

Patient Oral Plaster Model (Including antagonist)

Oral Scanning Data

Check bite

Other

Shipping Date (If applicable)

Date

How to ship CBCT files* This field is required.If you need a courier pick up service, please contact your sales person or One guide team (02-9889-2675)

How to ship plaster models / Impression / STL* This field is required.If you need a courier pick up service, please contact your sales person or One guide team (02-9889-2675)

Name of Partnet LinkPlease select one of following option.

3Shape Communicate

Medit Link

iTero MyAligntech

Sirona

Other

Product request date* This field is required.Surgical Plan and Guide Turnaround Times Standard Cases: 2–3 business days for the surgical plan, starting from the successful receipt of all required materials (CT scans and impressions, either stone model or intraoral scan file). Full Arch Cases: Up to 5 business days for the surgical plan after receipt of the same materials. Once the surgical plan is confirmed: Surgical Guide: Fabrication and dispatch will be completed within 3 business days following final confirmation. Temporary Crown Creation: This process may require an additional 1–3 business days. Please submit your request date at least 2–3 days prior to the surgery date to ensure timely preparation.

Date

Delivery Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Patient Information* This field is required.

Name of Patient

Gender

Age

Estimated bone density

Treatment Requirements

Initial fixation required

Immediate implantation after extraction

Other

CT Scan (DICOM) File UploadPlease upload your DICOM file as a ZIP archive format. * The maximum file size that can be uploaded at once is 1000MB.

Drag and drop files here

Select files to upload

Max. file size: 1.0GB

Intra Oral Scan (STL) File UploadPlease upload your STL file as a ZIP archive format.

Drag and drop files here

Select files to upload

Implant Site* This field is required.

Desirable Fixture specification

Tooth no

Diameter

Length(mm)

Fixture 1

Fixture 2

Fixture 3

Fixture 4

Fixture 5

Fixture 6

Fixture 1

Fixture 2

Fixture 3

Fixture 4

Fixture 5

Fixture 6

Tooth no

Diameter

Length(mm)

Tooth no

Diameter

Length(mm)

Tooth no

Diameter

Length(mm)

Tooth no

Diameter

Length(mm)

Tooth no

Diameter

Length(mm)

Tooth no

Diameter

Length(mm)

Select Fixture system

Make Temporary Tooth?* This field is required.

YESNO

Desired Temporary crown shade

Guide Hole TypePlease select your preferred guide hole type.

Close Type - Enough distance between jaws

Open Type - Short distance between jaws

Additional RequestsPlease specify if you have additional requests.