V2R Online Rx Form

YesNo

Customer name*

PrefixFirst NameLast Name

Customer e-mail address*

Please enter the e-mail address associated to your Smile in a Box clinician account.

Additional email address

Kindly provide, as necessary, the email address of your practice manager or an additional email address designated for the receipt of all communications

Prefered language

If you would like your case management in a different language, let us know and we will be happy to do so

Company name*

Shipping address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone number*

Mobile phone number (Optional)

Uncheck if you would like to unsubscribe from receiving text message notifications for this case

Straumann customer number*

Purchase Order Number

Should you need to add a PO, please enter it here. Note that all cases for the NHS, {my}dentist and BUPA require pre-authorisation.

Click here if you are submitting files for an ongoing case

Smile in a Box™ case reference number*

The 8-digit number used for all Smile in a Box communications

Patient Identifier*

Please provide a patient code or reference of your choice. We do not recommend providing names here.

SingleMultiple unitsFull arch / edentulous

Condition and treatment scope

Arch*

Loading Approach

Temporary restoration

Condition

Additional clinical observations

Implant system*

Guided Surgery Kit Neodent*

Indicate the surgeon's dominant hand? *

Indicate the surgeon's working position? *

We request that you provide pictures of the surgeon's working position, for different implant sites. See the example below.

Additionally, we request that you provide pictures of your the surgeon's working position, for different implant sites. This will allow us to plan the case according to your preference. See the example below.

Guided Surgery Kit Anthogyr*

Indicate the surgeon's dominant hand? *

Indicate the surgeon's working position? *

We request that you provide pictures of the surgeon's working position, for different implant sites. See the example below.

Guided Surgery Kit Straumann*

Indicate the surgeon's dominant hand? *

Indicate the surgeon's working position? *

We request that you provide pictures of the surgeon's working position, for different implant sites. See the example below.

Browse Files

Please upload your picture(s) here

Preferred alignment*

Numbering system

Implant sites (US)

Rows	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16

Implant sites (FDI)

Rows	18	17	16	15	14	13	12	11	21	22	23	24	25	26	27	28

Implant sites (US)

Rows	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17

Implant sites (FDI)

Rows	48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38

Sequential pin-supported solutionStackable solution

Click here for more information about the different guided surgery solutions

Additional instructions:

YesNo

Coloring/Shades

Tooth shade*

Arch Design*

Gum shade

Please note that only the shades A1 and B1 are available for the stackable provisional prosthesis.

YesNo

Please provide instructions and attach photos of the patient in section 6 (if available)

Should you want to expand on the information provided above and discuss prosthetics in more detail, please contact us (1-514-587-8359) or your partner lab.

Full ServiceModular Service

Surgical treatment planning by coDiagnostiX™Digital wax-up design by CARES® VisualSurgical guide design by coDiagnostiX™Temporary restoration design by CARES® VisualCentralized manufacturing of the surgical guidesCentralized manufacturing of the temporary restorationComponent order (implants, abutments and auxiliaries)

Custom impression tray3D printed master model

Interactive: Smile in a Box will contact you to schedule an online meeting to review and adjust the plan prior to submitting the report (mandatory for full arch restoration)Document-based: Smile in a Box will submit a report for you to review and approve

Our current standard procedure is to provide you with a printed treatment plan. If you prefer not to receive it in print format, please click here.

Important note on surgery scheduling:

Please allow 8 business days for treatment planning and manufacturing of single-unit/multiple-unit case, and 20 business days for treatment planning and manufacturing of full arch/edentulous case, excluding shipping and considering less than 24hr treatment plan approval

Planned surgery date (if known, see above):

YearMonthDay

You might not receive your Smile in a Box order on time

The chosen services cannot be delivered at the chosen date. Please select a new date.

Need help? Access our Scanning Protocol.

Upload your files here (patient pictures, CT scans in DICOM format and models in .stl format)

Browse Files

Please upload all files in .zip format.

If your files cannot be uploaded, please provide a link to a cloud storage (dropbox, box, drive, hightail, etc.):

IOS Data Exchange Case ID from your Virtuo Vivo™, Medit or 3shape scanner

Optional

General Notes

0/200

Signature*

Firma*

Please wait for the confirmation prior to navigating away from this page. Upon successful submission, you will also receive an e-mail confirmation.

1. Patient information

2. Implant configuration

STRAUMANN® FALCON

STRAUMANN® FALCON

STRAUMANN® FALCON

3. Prosthetic design

4. What would you like to include with your order?

5. Treatment Scheduling

6. File upload and submission