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Service Request 4.0

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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

Case Information

Sales Representative
Phone number and/or email address

Your Name*
Surgeon*
Surgery Date
MM slash DD slash YYYY

Service Request

Custom Surgical Solutions*

Planning Session

Planning Session
MM slash DD slash YYYY
Time
:
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.

AccuShape

Material Options*
Drainage Holes*
Edge Type*

AccuPlan TMJ Planning

TMJ Surgical Plan*

AccuPlan Orthognathic Planning

Surgical Planning*
Indicate region(s) of interest

Maxilla Plan

Mandible Plan

Mandible Surgery (Left Side)
Mandible Surgery (Right Side)
Mandible Surgery

Occlusion & Options

Final Occlusion*
Additional Details
Note: defining surgical movements now may speed up your planning session experience

Planned Surgical Movements

Maxillary Movement

AccuPlan CMF Reconstruction

Surgical Plan*
Surgical Access
Diagnosis

Graft Information

Graft Data*
Selecting "patient-specific" graft site requires the submission of graft site CT data.
Graft Side
Additional Details
Planning Session duration may be improved with these additional details.
Add Occlusal Data
Planning Dental Implants

Pedicle to Emerge

AccuPlate

AccuPlate
Your case manager will confirm whether or not this manufacturer's thread is available for AccuPlate.

AccuModel

Please describe anatomical area of interest.
Model Selection (Orthognathic)
Please indicate additional Service Options. May incur additional cost. (Select all that apply.)
Model Selection (Reconstruction)
Please indicate additional Service Options. May incur additional cost. (Select all that apply.)
Model Selection (AccuShape)
Please indicate additional Service Options. May incur additional cost. (Select all that apply.)
Model Selection (AccuModel)

Please describe the solution you need in detail.

Patient Data

Submission Method*
Graft Site CT Data Acknowledgement*
MM slash DD slash YYYY
Shipping

Shipping Information

Address

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When completed, the Service Request will direct you to your chosen data transfer method.
PHI Upload Consent*
MedCAD is compliant with Health and Human Services (HHS) requirements for HIPAA / HITECH including 45 CFR Part 160 and Part 164, as well as the HITECH Act.
MedCAD is committed to employing all methodologies and technologies available to protect the PHI we are entrusted with.

For digital data transfer, a secure web portal is employed as a method of communication that prevents unauthorized parties from being able to access or read any content while it is in transmission. I understand the risks associated with online communications, and I consent to the conditions outlined in the MedCAD Data Privacy Policy. In addition, as a Business Associate, I agree that I have obtained authorization from the Covered Entity to share PHI for a given purpose.

Questions? Glad to Help.

Our customer support team is ready for your call. Contact us at +1 (214) 453-8864 or support@medcad.com

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