SIGUIDE - Order Sheet

SIGUIDE
Order Form

This form has a Save and Continue latest option. Save your progress and submit responses later.

If you wish to complete this guided case in two stages, kindly add your email in order to complete the form later.

If you require any further information or assistance with this form, please feel free to contact us

siguide@southernimplants.com.au
IMPORTANT: If you do not have an account with Southern Implants Australia, contact our accounts office on 02 88662893 or email accounts@southernimplants.com.au
View Surgical Guidelines Here!
Clinician Information
1. Southern Implants Account Number*
2. Clinician*
Solutions Consultant Name (rep)*

First NameLast Name
Email*
example@example.com
Contact Number*
3. Postal Address (if different from recorded account address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
4. Surgery Date *

MonthDayYear
not patient's birthdate
5. Patient Name (Reference)*

First NameLast Name
6. If other, please list
7. Method of Shipping*

Digital DeliveryDigital and Postal Delivery
8. Select Guided System*

VERSAHSIREALTruGuidePilot GuideOther
9. Select where guide is required*
10. Insured Patient*
11. Select Implant Type*

Deep Conical (DC)External Hex (EX-HEX)Internal Hex (M-Series, PROVATA®)Internal Octagon (IT Connection)INVERTATRI-NEX®Other
12. Tooth Number/s*
13. Supply Implants*

YESNO
14. Include Cover Screw/s*

YESNO
15. Include Healing Abutment/s*

YESNO
16. Type of Surgery

Immediate ExtractionFlap-less SurgeryRaised Flap Surgery
17. Add Stabilizing Pins*

YESNO
18. Any other information we need to know of?
Disclaimer: In no event will Southern Implants Australia be liable to any party or for any direct, indirect, special, or other consequential damages, including without limitation, any lost profits, business interruption, or otherwise. Under no circumstances will Southern Implants Australia assume diagnosis, prognosis, or a course of treatment. Suitability of the product and/or service for the intended use will remain the risk and liability of the client. If the client does not supply dimensions, the technician will select the best possible length and diameter for approval by the clinician.

SIA will not be held responsible for any costs associated with the cancellation of the SIGuide or if it is no longer required. Any changes or cancellations of orders made after the submission of this form, will not be the responsibility of Southern Implants Australia.

SIA will not accept responsibility for any parcel deliveries. We recommend that parcels are sent with registered post/couriers to obtain proof of shipment.
Shipping Instructions (shipping address has changed!!):

If you were unable to upload the files or have a model instead of a scan, please print a copy of this form and send it along with the following items, raw Dicom data, models and any diagnostic wax-ups to

Attention: SI-GUIDE

Southern Implants Australia, NSW Office

Suite 3.12, 32 Delhi Road Macquarie Park NSW 2113

T: +61 (02) 8076 9337

E: nsw@southernimplants.com.au

Please allow 10-15 working days for planning and manufacturing.
IMPORTANT

Please revert back to this page to submit your surgical guide case. We won't receive your patient information if this Jotform has not been submitted.

To transfer files on WeTransfer please use siguide@southernimplants.com.au

Please use your patient name as references in the message box.

Click HERE to upload STL

Click HERE to upload DICOM (Zip prior to sending)
Your case will be not be submitted without the STL and DICOM files.

Please hit the 'submit' button below in order to complete this surgical guide case.
Should be Empty: