Guided Flow Rx For Surgeons

SPECIALIST INFORMATION *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Restorative Doctor Name *

First Name

Last Name

Phone

(###)

###

####

Patient Name *

First Name

Last Name

Gender *

Male

Female

Please let us know who should be charged for which steps *

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

Radiology Report *

Would you like to add a Radiology Report to your order and have the scan interpreted by a radiologist (+$125)? Standard turnaround time to forward scan to radiologist is 5 to 7 business days and rush cases are completed by the end of the next business day for an additional fee.

Yes

Yes rush (+$50)

No

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.