Registration form for surgical guides for zygomatic or pterygoid implants

Name of surgeon / prescriber

Surgeon's / prescriber's last name

Surgeon's / prescriber's cell phone

Surgeon's / prescriber's contact email address

Patient's medical record number

Patient initials

Type of surgery to be performed:

You have a date of surgery

Yes No

Expected date of surgery

Expected number of implants for the treatment (pilot surgery)

Zygoma Implants

Pterygoid Implants

Mesial Implants

Brief explanation of the treatment

Do you want to add a drilling resin model with a duplicate of the guides to drill priory to the surgery with extra cost + 406,1 €

Yes No

Guide shipping data

Name of clinic or hospital

To the attention of

Street

Number

Population

Postal Code

Clinic or hospital phone number

I agree to the terms of service.

GDPR Data Protection Legislation

I give my consent for this website to store the information submitted so that they can respond to my inquiry

CT in DICOM format (helical CT or CBCT) or double CT (patient and radiographic guide with gutta-percha markers).

You can add the planning performed with an implant planning software (DTX, RealGuide, ImplaStation, etc.).