Step 1: File Verification Doctor name *
First
Last
Patient name *
First
Last
File Upload
Step 2: Doctor and Patient Info Doctor Address * Placing Doctor name *
First
Last
Placing Doctor Address * Restorative Doctor name *
First
Last
Restorative Doctor Address *
Same as Placing Doctor
Treatment Info Do you require a JC Try-in? Single arch additional options
Maxillary Arch
Mandibular Arch
Patient Records & Case Design
Surgery Information Acknowledgment * Schedule surgery after the online meeting * CHROME Timeline
Split Fee Arrangement Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fees are not available on this form for this particular package. Please note how you want these fees split in the notes field below.
Split Fee: CHROME Standard - Single Arch Tooth & Implant Planning ($300) Surgical Guides ($1,750) Prosthetic & RAPID Guide ($650) Backup Denture ($154) Final Prosthesis ($3,399) Optional: Stellar/VOCO acrylic Optional: Fixation Kit(s) Optional: Additional denture(s) Optional: JC Try-in(s)
Split Fee: CHROME Standard - Double Arch Tooth & Implant Planning ($300 x2) Surgical Guides ($1,750 x2) Prosthetic & RAPID Guide ($650 x2) Backup Denture ($154x2) Final Prosthesis ($3,399 x2) Optional: Stellar/VOCO acrylic Optional: Fixation Kit(s) Optional: Additional denture(s) Optional: JC Try-in(s)
Split Fee: CHROME Natural - Single Arch Tooth & Implant Planning ($325) Surgical Guides ($1,950) Optional Labial and/or Scallop Surgical Guides Prosthetic & RAPID Guide ($650) Backup Denture ($154) Final Prosthesis ($3,399) Optional: Stellar/VOCO acrylic Optional: Fixation Kit(s) Optional: Additional denture(s) Optional: JC Try-in(s)
Split Fee: CHROME Natural - Double Arch Tooth & Implant Planning ($325 x2) Surgical Guides ($1,950 x2) Optional Labial and/or Scallop Surgical Guides Prosthetic & RAPID Guide ($650 x2) Backup Denture ($154x2) Prepaid Final & 2 Prototypes ($3,399) Optional: Stellar/VOCO acrylic Optional: Fixation Kit(s) Optional: Additional denture(s) Optional: JC Try-in(s)
Master Surgical Agreement Master Surgical Agreement Consent * I agree to the Master Surgical Guide Agreement per the text below
Total Important information: CHROME prepaid packages are intended to cover all costs, but are limited in scope. OEM parts during the restorative phase will increase the cost of all cases, and several implant brands require OEM parts. Please contact us if an estimate is needed. Full package Rx cost estimates DO NOT include the cost for OEM parts.
Once you click Submit Rx and go to Records Upload a pdf copy of CHROME Rx will be emailed to you – if you do not see this email appear immediately please check your spam/junk folder.
If the "Submit Rx and go to Scheduling" button is not appearing below, please go to the top of the Rx and click the "Upload Files" button. When file upload is complete, the submit button below will appear.
