Please fill in the information required below for Implant Planning

Doctor's Full Name(required)

Your Email Address(required)

Your Phone Number(required)

Address(required)

Patient's Full Name(required)

Requested Surgery Date (Ex: YYYY-MM-D)

Order Description : Yes/No

3D ConversionImplant PlanningGuide Fabrication

Jaw Information.

MandibleMaxillaBoth
Number Of Implants :
Desired location for implants:(Example : 11, 21 , 25 ,44 ,45)

Preferred implant:

Preferred size:

Increase A/P spread using angled implants? :

YesNo

Immediate extractions to be performed at time of surgery? :

YesNo

Bone grafting to be performed at time of surgery? :

YesNo

Bone reduction to be performed at time of surgery? :

YesNo

Surgical kit to be used: (Ex:Nobel ,strauman.....)

Drill Key outer diameter size and length: (Ex:2.1mm and 21mm.....)

Restorative plan :

Single crownsSplinted crownsScrew retained OverdentureOverdenture on a barOverdenture on Locator attachments

Order Form

Updated on 2015-05-23T09:26:30+00:00, by Simon.