360 Upload, Claudio

Swiss Dental Account #*

Use your phone number as your account number

Dentist Name:*

PrefixFirst NameLast Name

License #:*

Case Delivery Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail:*

Patient Name*

Shade*

Materials Shipped*

Bite registrationModels/impressionsDICOM files on CD (or upload them here)None

Arch to treat*

MaxillaMandibleBoth

Implant Make and Line*

Surgical kit to be used*

Please list further details, instructions, requirements or other information here.

Surgery should be scheduled only after you have signed and returned the treatment plan approval form, which can only be made after all necessary scans/models/etc have been submitted. If you have scheduled a surgery, please include the date above.

Begin work?*

Please begin case, I consent to fees incurred in the process of diagnostic assesment and treatment planning.

File Upload (Please ZIP DICOM files):

Upload a File