Noris Medical – EZGoma Rx

Important Instruction – please follow exactly

Step 1: Complete the Rx below and submit
Step 2: On the next page, you will be prompted to upload your patient records
Step 3: Check your confirmation email to book your Implant Planning Meeting with one of our specialists.

If you have any questions, please call (800) 763-7821 ! If after hours, email ct@guidedsmile.com

Submitter's Info

Submitter's Name(Required)

First Last

Patient Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Case Information

EZGoma(Required)

Left Position(Required)

Right Position(Required)

Pterygoid Sites

Pterygoid Site Location

Pterygoid Implant Line

Standard Implant Sites

Number of Additional Implant Sites

$89/each

Implant Site Numbers (1-16)

Standard Implants

Nasalus Implants

Nasalus Implant Site

Add Ons

Additional Skull Print (standard comes with one) - $109

Yes - Skull Print

No - Skull Print

Additional Clear Skull Print - $265

Add'l Clear Skull Print - Yes

Add'l Clear Skull Print - No

Bone reduction guide, labial only, plastic - $159

Bone reduction guide - Yes

Bone reduction guide - No

Prosthesis w/ Holes for pick-up (requires either full dentate IOS scan, or Dual Scan protocol) - $359(Required)

Pick Up Prosthesis - Yes

Pick Up Prosthesis - No

Do you need a preview of the guide prior to fabrication, or does the live meeting constitute approval?(Required)

Live meeting constitutes approval

I'd like to see the design for approval before fabrication

Total

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