Dental Practice: *

Company

Dentist Name: *

First Name Last Name

Dentist Phone: *

Best Contact Number

Dentist Email Address: *

Email

Patient Name: *

First Name Last Name

Date of Surgery/Date Required *

File Upload

Please choose Digital STL File or Model *

Digital STL File Stone Model/Silicone Impression (Pls send model to Jade Dental Laboratory PO Box 808, Buderim Q 4558)

Copy Link to STL Folder Here

eg link to dropbox folder or google drive folder

Copy Link to Dicom Folder Here *

eg link to dropbox folder or google drive folder

Information about the surgical guide system

Brand and Name of Surgical Kit *

eg Southern Implants, Neoss, Nobel

Method of Implant Placement *

Fully Guided Pilot Drill Guided

Surgical Drills Planned for Procedure *

	Drill 1	Drill 2	Drill 3	Drill 4	Drill 5
Length mm
Diameter mm

**IMPORTANT - LENGTH IS MEASURED FROM THE APEX OF THE BUR TO THE STOPPER OR MAXIUMUM WORKING LENGTH**

Position of Implants

Please specify the position type and size of implants: *

	Tooth Site	Implant Brand	Implant Type	Implant Length mm	Implant Diameter mm
Implant 1
Implant 2
Implant 3
Implant 4
Implant 5
Implant 6
Implant 7
Implant 8

Comments/Notes

Would You Like to Discuss Case *

Yes, I will call you No, please plan and send for approval

By ticking this box, I understand the following: *

I agree that information provided is true and correct; Models/STL and Dicoms are recent and accurate; I understand that by submitting this form, I agree to a non refundable planning fee of $80.00.

Jade Dental Terms and Conditions

Implant Planning Form