MedCAD Service Request V4 Step 1 of 5 20% Please complete the following service request to begin your case. Press Next to continue. Important Notes: CMF CT/CBCT Scanning Protocol - Please make sure your CT submission meets our CT protocol. Please do not enter any patient names on this form. If you require immediate assistance, please call (214) 453-8864. MEDCAD TEAM Please acknowledge before proceeding* To ensure the timely processing of your case, it is essential to submit a complete service request along with the required patient scan. Please coordinate with relevant parties to gather all required information for submission. Incomplete submissions may result in delays. Thank you for your attention to this matter and for helping us provide the best possible service HiddenCase Number HiddenUser Role Case InformationYour RoleSales RepresentativeSurgeonOffice AdminOtherOther Role* Company* Your Name* First Last Your Mobile Phone*Your Email* Surgeon* First Last Surgeon Email Sales Representative First Last Hospital* Surgery Date Not Scheduled Scheduled Surgery Date* MM slash DD slash YYYY Select ProductsMedCAD Patient-Specific Products* Cranial Implants - AccuShape CMF Reconstruction - AccuPlan Orthognathic - AccuPlan 3D Anatomical Model - AccuModel TMJ Planning - AccuPlan Other / Not Sure AccuShape® Cranial ImplantMaterial Options* PEEK Titanium Drainage Holes*Please indicate drainage hole preference. (Select one) Include holes No Holes Other/Not Sure Add-On ServicesPlease indicate additional Service Options. May incur additional cost. (Select all that apply.) Implant Template Model Peri-Defect (Host Bone) Model Browse more AccuModel options Edge Type*Standard Edge (Default)Custom Edge (Please Specify)Custom Edge Specification*AccuPlan® TMJ PlanningTMJ Planning for* Patient Left Patient Right DetailsAdditional Services Include Orthognathic Planning AccuPlan TMJ - ModelsPlease indicate add-on services here. May incur additional cost. (Select one or more) Pre-Op Mandible Model Pre-Op Maxilla Model Post-Op Mandible Model Post-Op Maxilla Model Other AccuPlan® Orthognathic PlanningPatient-Specific Orthognathic Surgical Planning Orthognathic Notice! To begin a case, MedCAD needs all of the following items: CT ScanStone models & Bite index (OR Intraoral Scan)Service Request OR Order Form If you are sending stone models you may continue with this service request or complete the physical form and send case requirements to 501 S 2nd Ave. Ste A-1000, Dallas, TX 75226. If you are sending intraoral scans, please proceed with this service request. Surgical PlanSurgical Plan Mandible Maxilla Please indicate area(s) of interest.Maxilla PlanMaxilla LeFort* LeFort I LeFort II LeFort III Maxilla Segments*Please enter a number from 1 to 5.Mandible PlanMandible Surgery (Left Side) Sagittal Split Osteotomy (SSO) Vertical Ramus Inverted L Subapical Osteotomy Other Mandible Surgery (Right Side) Sagittal Split Osteotomy (SSO) Vertical Ramus Inverted L Subapical Osteotomy Other Mandible Surgery Genioplasty Mandibular Split Other Mandible Plan - Other* Occlusion & OptionsFinal Occlusion* I will send Final Occlusion Stone Models I want MedCAD to digitally set the Final Occlusion N/A Surgical Movements Define Surgical Movements Later in the Planning Session Define Surgical Movements Now Note: defining surgical movements now may speed up your planning session experienceAdd Anatomical Models Yes Model Selection (Orthognathic) Pre Op Mandible Pre Op Maxilla Post Op Mandible Post Op Maxilla Other Other Details Surgical MovementsMidline Correction-------Patient RightPatient LeftN/ALandmark indicating focus of correction.Midline Correction (mm)Occlusal Plane Angle Correction-------IncreaseDecreaseOcclusal Plane Angle Correction (degrees)Please enter a number from 0 to 30.Occlusal Plane Position Correction-------1st Molar Impaction1st Molar Down FractureOcclusal Plane Position Correction (mm)Please enter a number from 0 to 30.Maxillary MovementAdvancement/Setback-------AdvancementSetbackAdvancement/Setback (mm)Impaction/Down Fracture-------ImpactionDown FractureImpaction/Down Fracture (mm)Custom Plates + Guides Lefort Plates Mandible Plates Genio Plates Guides N/A Screw Manufacturer AccuPlan® Reconstruction Surgical Planning for Oral-Maxillofacial ReconstructionAccuPlan CMF ReconstructionSurgical Plan* Free Flap Reconstruction Trauma Reconstruction Resection Only (No Graft) Surgical Access-------IntraoralExtraoralDiagnosis-------BenignMalignantN/AAdd Occlusal Data Set On Meeting Final Bite Provided Add Anatomical Models Yes AccuPlan Recon - ModelsPlease indicate add-on services here. Select one or more. Pre-Op Anatomical Model Post-Op Anatomical Model Graft Site Anatomical Model Other AccuPlan Recon - Models - Other Add Patient Specific Guides Resin Guides Titanium Guides Planning Dental Implants Yes No Graft PlanGraft Data* Patient Specific Generic Data Selecting "patient-specific" graft site requires the submission of graft site CT data.Graft Site Anatomy*-------FibulaIlliac CrestOtherGraft Side-------LeftRightTo Be DeterminedAcknowledgement* I will send patient graft data to MedCAD (i.e. CT of fibula) Additional Details Add Surgical Plan for Graft Planning Session duration may be improved with these additional details.Predicted # of Graft SegmentsPedicle to Emerge Anterior Posterior Left Right AccuModel® 3D Anatomical ModelModel Options* Skull With Mandible Skull (No Mandible) Maxilla & Mandible (Fused) Maxilla Mandible Other Other Model Details Additional NotesAdditional NotesAccuPlateAccuPlate Add Milled Titanium Plate (Locking Thread) Add 3D Printed Titanium Plate(s) (Non-Locking) Add Orbital Floor Plate(s) Add Pre Bent Plate Screw Manufacturer Your case manager will confirm whether or not this manufacturer's thread is available for AccuPlate.Mandible Plate Instructions Planning SessionPlanning Session Request Meeting Now Contact Me to Schedule Not Sure N/A Requested Planning Session Date MM slash DD slash YYYY Requested Planning Session Time : Hours Minutes AM PM Surgeon Time Zone* Note! Most cases require at least 24 hours between the approval of all input and the Planning Session. By requesting a meeting, we do not guarantee the meeting time will be available though we will do our best to accommodate. For additional support, please contact your Case Manager at +1 (214) 453-8864 x 1. Submit SR Yes Select Yes if you are ready to submit the service request as an order for products. Once Yes is selected, you may press the "next" button below to submit. SubmissionSubmit Data* Upload CT (Recommended) FedEx CT Already Submitted CT Waiting on CT CT Scan Date* MM slash DD slash YYYY Expected CT Date* MM slash DD slash YYYY Patient Initials* Submission Method*Select One...UploadFedExUPSUSPSHand DeliveryWhat method did you use to send the data for this case?Tracking Number Also submitting:* Intraoral Scan Stone Models Bite Index Quick LinksCMF CT Scanning Protocol CT Upload InstructionsShipping Information Click here to add shipping information. 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