Simple Surgical Guide – Lab Order Rx

Step 1 of 2: Submit Online Rx

Welcome to the new Surgical Guide Rx.

Steps:

Complete the form and click “Submit RX and go to Records Upload.” Your Rx will be sent to GuidedSMILE, and you’ll receive a confirmation email.
Upload your records on the next page. Once uploaded, your case submission is complete.
If GuidedSMILE is planning your case, you’ll approve the implant plan before surgical guide production begins.

If you have any questions, please email ct@guidedsmile.com

"*" indicates required fields

Lab/Patient Info

Name Of Submitting Lab*

Lab Contact Name*

First Last

Lab Contact Email*

Lab Contact Cell Phone*

Patient Last Name*

Desired Return Date*

Surgical Guide Info

Type of Guide Needed*

Who is planning the implants?*

GuidedSMILE to plan implants = $81 for first implant site. $18/each additional site.

It is submitting lab's responsibility to schedule the implant planning meeting between the doctor and GuidedSMILE. An email will be sent to the lab rep email with the scheduling link.

Who is designing the guide?*

GuidedSMILE to design surgical guides = $59

GuidedSMILE Bone Channel Guide Design Charge*

Price:

Who is fabricating the guide?*

GuidedSMILE to fabricate guides = $90

Bone Reduction Guide

Fixation Base Material*

Who is planning?*

GuidedSMILE to provide Report and Screenshots for Approval - $89*

Yes

GuidedSMILE to host live meeting with doctor - $150*

Yes

VDO - Open or Close Patient Vertical*

Measurement in mm

It is submitting lab's responsibility to schedule the implant planning meeting between the doctor and GuidedSMILE. An email will be sent to the lab rep email with the scheduling link.

Who is designing the guide?*

GuidedSMILE to design bone reduction guides = $188

GuidedSMILE Fabrication Charge*

Price:

Who is fabricating the guide?*

GuidedSMILE to fabricate bone reduction guides = $198

Requires 3 reusable Stacking Pins and 3 Fixation Sleeves. Please order below.

Planning

Additional Implant Sites*

Tooth Numbers*

Implant Brand*

Guided Kit*

Design

What format is the plan in?*

Other System*

How will the implant plan be shared?*

Other Submission Method*

Design

What format is the plan in?*

Other System*

How will the implant plan be shared?*

Other Submission Method*

Design

What format is the plan in?*

Other System*

How will the implant plan be shared?*

Other Submission Method*

Fabrication

How will the design be shared?*

Other method of sharing design*

Does the guide need sleeves?*

How many sleeves?*

Please enter a number from 0 to 13.

Cost per sleeve = $18

Sleeve Charge

Price: $0.00

Add Ons

LITE Stacking Pins (Set of 3 pins)

Price: $126.00

Fixation Kit - Long

Price: $215.00

Includes 1 Long Drill, and 4 Long Pins

Fixation Kit - Short

Price: $215.00

Includes 1 Short Drill, and 4 Short Pins

Fixation Drill - Long

Price: $72.00

Fixation Drill - Short

Price: $72.00

Fixation Pin - Long

Price: $36.00

Fixation Pin - Short

Price: $36.00

Additional Notes

Billing and Payment

Order Total

Name On Card*

First Last

Credit Card*

Card Details

Cardholder Name

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code

Shipping Address Matches Billing Address

Shipping Address

Street Address City State / Province / Region ZIP / Postal Code

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Simple Surgical Guide – Lab Order Rx

Step 1 of 2: Submit Online Rx

Lab/Patient Info

Surgical Guide Info

Bone Reduction Guide

Planning

Design

Design

Design

Fabrication

Add Ons

Billing and Payment