Guided Flow Rx For Restorative DoctorsUse this Rx to provide us the necessary information for the design of your patient’s temporary. RESTORATIVE DOCTOR INFORMATION Restorative Doctor Name * First Name Last Name Practice Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Dental License Number * Phone (###) ### #### Email SPECIALIST INFORMATION * First Name Last Name Phone * (###) ### #### Email * Please provide us the email address to which we will send you the surgical plan PATIENT INFORMATION Patient Name * First Name Last Name Gender * Male Female FINAL RESTORATIVE CHOICE Payment Information Our guided workflow includes, a flap guide, pin positioning guide, bone reduction guide, implant surgical guide, abutment guide, secured surgical PMMA, secured VOS appliance, clear pick-up washers and cylinder blockers. It does NOT include chairside support, Multi-Unit/SRA, temporary cylinders. Bundled Options * Would you like to take advantage of substantial savings opportunities by bundling your guided surgery with your final restoration today? If you choose to order the final restoration at a later time, savings will not apply. Please Choose Yes, I want to pre-order my final restoration today No, thank you Future plan Are you planning to restore the opposing? Yes No Upper Final Restoration * Please tell us which final upper restoration you would like so we can better evaluate the appropriate bone reduction. Please Choose NA Crystal Ultra Opal Z (Zirconia) Opal Z with Titanium Bar Opal Z Premium (Titanium bar with individual zirconia crowns) Lower Final Restoration * Please tell us which final lower restoration you would like so we can better evaluate the appropriate bone reduction. Please Choose NA Crystal Ultra Opal Z (Zirconia) Opal Z with Titanium Bar Opal Z Premium (Titanium bar with individual zirconia crowns) Please let us know who should be charged for which steps. * Payment due before services rendered once the plan has been approved Charge the Specialist for the guides and PMMA Charge the Specialist for the guides, PMMA, and final restoration Charge The Restorative Doctor for the Final Charge the Restorative Doctor for the guides, PMMA, and final restoration Please Explain CASE REQUIREMENTS Upon completing this Rx, you will be redirected to our Uplink, where you can send us the corresponding scan files and photos. Failure to complete these steps will result in delays to your case. IOS Scan or Impressions * Please Choose Regular Impressions 3Shape Trios Carestream Dental - CS 3700 Dental Wings Virtuo Vivo Dentsply Sirona - CEREC Primescan Itero Element 5D Medit - i500 Planmeca - Emerald S Vatech - EzScan Facial Scanners Please choose Bellus 3D InstaRisa scanner InstaRisa Tablet Clinical Photos * Please Choose Sending Not Completed Additional Smile Design Information Notes: TEMPORARY INFORMATION PMMA Temporary * Please let us know if you want a PMMA temporary for delivery the day of surgery. Please Choose Yes, I would like a PMMA No, I do NOT want a PMMA I want a denture instead of a PMMA Immediate Denture * Please let us know if you want an immediate emergency denture the day of surgery, just in case you can't load. Please Choose Premium Denture ($500) Economy Denture ($250) (A1 only, printed denture) No denture needed Shade * Please Choose OM1 OM2 OM3 A1 A2 A3 A3.5 A4 B1 B2 B3 B4 C1 C2 C3 C4 D2 D3 D4 Gingiva Shade * Please Choose No Pink Light Regular Ethnic Teeth Shape * Allure's choice Copy Existing Shape of Teeth Improve Shape of Teeth Please explain Opening the VDO * Please let us know if you are opening the VDO and by how much. Please Choose N/A 0.5 mm 1.0 mm 1.5 mm 2.0 mm 2.5 mm 3.0 mm 3.5 mm 4.0 mm 4.5 mm Closing the VDO * Please let us know if you are closing the VDO and by how much. Please Choose N/A 0.5 mm 1.0 mm 1.5 mm 2.0 mm 2.5 mm 3.0 mm 3.5 mm 4.0 mm 4.5 mm Articulators Preference Let us know which articulator you would like Allure Dental Studio to use on your case. Please Choose Allure's favorite Panadent Stratos Sam 3 Denar regular Denar magnetic Incisal Display * How much incisal display would you like? Please Choose 0 mm 0.5 mm 1.0 mm 1.5 mm 2.0 mm 2.5 mm 3.0 mm 3.5 mm 4.0 mm 4.5 mm Select how you would like to have the case approved: * Please call me when ready Please email me when ready Please click "Terms and Conditions" below and read carefully * TERMS AND CONDITIONS By checking this box, you are acknowledging that you agree to our payment terms and conditions and that all the information you provided is accurate and verified. Clients agrees to pay any collection costs incurred in the collection of any delinquent account including reasonable attorney fees. TERMS AND CONDITIONS Thank you for filling out the Non-Guided Rx: Pre-Surgery Data Set.Please upload your files here, so that we may merge and align the files in our proprietary software to create a 3D-virtual patient and their new smile.
