Start Your Virtual Implant Rx

Please complete the following form in its entirety. Fields marked with a red asterisk are required.
What 3D planning software are you using? *
  Simplant Planner
  Simplant Pro
  Simplant Master
  NobelGuide
  None
Patient Information
Name *
First
 
 Last
Age
Gender
Restorative Doctor/Surgical Specalist Information
If not applicable, skip section
Restorative Doctor's Name *
   
 
First
 
 Last
Can we provide a copy of the surgical/restorative report to the restorative Doctor? *
  Yes
  No
Restorative Doctor's Phone Number
      ###
 
      ###
 
       ####
Restorative Doctor's Email *
Restorative Doctor's Address
Street Address
Address Line 2
City
 
  State / Province / Region
Postal / Zip Code
  Country
Restorative Doctor's Mobile Number
      ###
 
       ###
 
       ####
Restorative Doctor's Fax Number
      ###
 
       ###
 
       ####
   
Surgicial Specalist's Name
First
 
 Last
Surgical Specialist's Phone Number
      ###
 
       ###
 
       ####
Surgical Specialist's Email *
Surgical Specialist's Address
Street Address
Address Line 2
City
 
  State / Province / Region
Postal / Zip Code
  Country
Surgical Specialist's Mobile Number
      ###
 
       ###
 
       ####
Surgical Specialist's Fax Number
      ###
 
       ###
 
       ####
Questionnaire
What is the desired final prothesis? *
How will the surgical guide be supported (tooth, bone,
or tissue?) *
All tooth supported guides require a working model sent.
Was a model sent to lab? *
  Yes
  No
What brand implants are you planning to use? *
All NobelGuide procedures begin with a radiographic guide.
Was a dual scan protocol used?*
  Yes
  No
Do you currently have CT guided surgical instrumentation?
If yes, please list. *
What type of provisionalization are you planning on utilizing? *
Desired Implant Location: *
Input as numbers. Example: 7, 8, 9, 10
Implant Placement / Treatment / Notes
Additional Information
   Please provide quote for this treatment plan
   Case is due within the next two weeks, please rush this case
Please note that this may not always be possible. Van Hook Dental
Studio will determine if this is possible for the case. A rush fee may
apply.
How did you hear about us?
Digital Signature
By entering your electronic signature, You hereby authorize Van Hook Dental Studio to apply charges for
services rendered to your account and begin planning this case.

Signature *
First
 
 Last
Date