Scan Submission Form

Please answer the following*

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

Instructions

Surgial Guide Type
Maxilla*

YesNo
Type of Guide

Partial Edentulous GuideSingle-piece Edentulous GuideStackable Guide SetUndecided
Guide for Flap or Flapless Surgery

Flap SurgeryFlapless SurgeryUndecided
If you are ordering an edentulous guide, which part of oral structure would you like the surgical guide to engage:

Mucosa-borne GuideBone-borne GuideBone & Tissue Borne Hybrid Guide (Cross incision flap required)Undecided

Which surgical guide parts do you need?*

Rows	Yes	No
Bone Reduction Jig
Surgical Drill Guide
Stackable Transfer jig
Stackable PMMA Long-term Provisional
Backup Immediate Denture

If you are ordering a provisional:
If you are ordering a provisional (Stackable or independent)

Stackable provisional STL file only - to be process by youNon-stackable provisional milled and stained based on your design STL fileNon-stackable provisional milled based on your design STL file (not finished)
Type of backup denture if ordering:

MilledProcessed
Mandible*

YesNoOther
Type of Guide

Partial Edentulous GuideSingle-piece Edentulous GuideStackable Guide SetUndecided
Flap or Flapless Surgery

Flap SurgeryFlapless SurgeryUndecided
If you are ordering an edentulous guide, which part of oral structure would you like the surgical guide to engage:

Mucosa-borne GuideBone-borne GuideBone & Tissue Borne Hybrid Guide (Cross incision flap required)Undecided

Which surgical guide parts do you need?*

Rows	Yes	No
Bone Reduction Jig
Surgical Drill Guide
Stackable Transfer jig
Stackable PMMA Long-term Provisional
Backup Immediate Denture

If you are ordering a provisional:
If you are ordering a provisional (Stackable or independent)

Stackable provisional STL file only - to be process by youNon-stackable provisional milled and stained based on your design STL fileNon-stackable provisional milled based on your design STL file (not finished)
Type of backup denture if ordering:

MilledProcessed
Implant Brand*
Company (i.e. Nobel )
Product Line *
Accurate Implant Product Name (i.e. NobelActive)
Pilot Drill Guide or Guide for a Guided Surgery System?*
Drill Guide Sleeve Position
Guided Surgery System Name
(i.e. Straumann System)
If you are ordering a provisional, please provide the following:
Teeth & Gum Tissue Shade
Teeth #s the provisional(s) to cover

Additional Parts and Supplies*

Rows	Yes	No
Fixation Drill
Fixation Screws
Driver Handle for Fixation Drill
Acrylic Resin Kit for PMMA Provisional

Type of fixation drill if ordering:

ContraStraight
Is an imaging center submitting scan data for this patinet?*

YesNo
Name of the Imaging Center
Teeth #s / # of implant
Other special instructions (if any)
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:

Surgical Guide Order Form (for Your Surgical Plan)