V2R Online Rx Form

Are you a registered Smile in a Box customer? *

Yes No

Please submit your information and we will contact you shortly.

Please enter your e-mail address *

Customer name *

First Name Last Name

Customer e-mail address *

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

Company name

Shipping address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Shipping address

Street address, City, State, Zip Code, Country

Phone number

Straumann customer number

Patient full name / Case reference number *

Case type *

Single Multiple units Full arch / edentulous

Condition and treatment scope

Arch *

Condition

Loading Approach

Temporary restoration

Additional clinical observations

Implant system

Surgical kit

Number of implants

Preferred alignment

Numbering system

Implant sites (US)

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

Implant sites (FDI)

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

Implant sites (US)

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

Implant sites (FDI)

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

Preferred guided surgery solution

Sequential pin-supported solution Stackable solution

Additional instructions:

Would you like to order a temporary restoration?

Yes No

Coloring/Shades

Tooth shade *

Gum shade

Will you be providing a mock-up of the temporary?

Yes No

Additional instructions

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.

Additional ordered services

Custom tray Scan appliance Fast delivery (Priority line) Anatomical model

Preferred treatment plan review method *

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

Preferred treatment plan review method *

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

Important note on surgery scheduling:

Our design and manufacturing turnaround is 10 business days, initiated following the final approval by the clinician.

As case initiation (submission and lab processing) turnarounds are less predictable, we highly recommend to schedule the surgery after submitting the treatment plan approval.

Planned surgery date (if known, see above):

Year Month Day Date Picker Icon

The planned surgery date entered leaves insufficient time to process the case. We highly recommend to schedule the surgery only once the treatment plan has been approved.

Upload your files here:

Browse Files

Please note that the maximal file size is 1 Gb for single file upload and 100 Mb for multiple files upload. 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.):

Signature *

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Firma *

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

1. Patient information

2. Implant configuration

3. Prosthetic design

4. Workflow planning & form submission