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Service Request 3.0

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Please complete the following service request to begin your case. Press Next to continue.

Important Notes:
  • As of September 21, 2021, this form has been updated! Read more about the change here.
  • 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

Drainage Holes*
Edge Type*
Additional Holes

AccuPlan TMJ Planning

TMJ Surgical Plan*

AccuPlan Orthognathic Planning

Orthognathic Surgical Plan*

Maxilla Plan

Le Fort II's and III's are uncommon, please verify this is accurate.

Mandible Plan

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

Occlusion & Options

Dental Data Supplied by Customer*
Dental data is required for Orthognathic planning. This can be uploaded or shipped directly to MedCAD.
Final Occlusion*
Dental Splints
Additional Details
Planning Session duration may be improved with these additional details.

Clinical Measurements

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.

Please enter a number greater than or equal to 0.
0 indicates flush with the inferior border, greater than 0 indicates millimeters above the inferior border
Pedicle to Emerge

AccuPlate

AccuPlate
May incur additional cost.
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 & TMJ)
May incur additional cost.
Model Selection (Mandible Reconstruction)
May incur additional cost.
Model Selection (AccuShape)
May incur additional cost.
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.
Privacy Policy*
Terms and Conditions*

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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