Service Request 4.0 "*" indicates required fields Step 1 of 5 20% HiddenMCID HiddenMCID - Case To sync with Cases AppPlease 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 InformationYour Role*Sales RepresentativeSurgeonSurgical AssistantOtherOther Role* Sales Representative First Last Company* Sales Representative Contact Information Phone number and/or email addressYour Name* First Last Your Phone*Your Email* Surgeon* Dr.Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Surgeon Email* Hospital* Patient Initials* Surgery Date Not Scheduled Surgery Date* MM slash DD slash YYYY Service RequestCustom Surgical Solutions* Cranial Implants - AccuShape Orthognathic - AccuPlan CMF Reconstruction -AccuPlan 3D Anatomical Model - AccuModel Other / Not Sure Planning SessionPlanning Session Request meeting now Contact me to schedule Not Sure N/A Requested Meeting Date* MM slash DD slash YYYY 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. AccuShapeMaterial Options* PEEK Titanium Drainage Holes* Include Holes No Holes Other / Not sure Edge Type* Standard Edge (Default) Custom Edge(Please Specify) Custom Edge Specifications*AccuPlan TMJ PlanningTMJ Surgical Plan* Patient Left Patient Right Include Orthognathic Planning TMJ Planning SpecificationsAccuPlan Orthognathic PlanningSurgical Planning* Mandible Maxilla Indicate region(s) of interestMaxilla PlanMaxilla Le Fort*Le Fort ILe Fort IILe Fort IIIMaxilla Segments*Mandible PlanMandible Surgery (Left Side) Sagittal Split Osteotomy (SSO) Vertical Ramus Inverted L Subapical Osteotomy Other N/A Mandible Surgery (Right Side) Sagittal Split Osteotomy (SSO) Vertical Ramus Inverted L Subapical Osteotomy Other N/A Mandible Surgery Genioplasty Mandibular Split Other N/A Other Mandible SurgeryOcclusion & OptionsFinal Occlusion* I will send Final Occlusion Stone Models I want MedCAD to digitally set the Final Occlusion N/A Additional Details Define Surgical Movements Later in the Planning Session Define Surgical Movements Now Note: defining surgical movements now may speed up your planning session experiencePlanned Surgical MovementsMidline CorrectionPatient RightPatient LeftN/AMidline Correction (mm)Occlusal Plane Angle CorrectionIncreaseDecreaseN/ACurrent Occlusal Plane AngleOcclusal Plane Position Correction1st Molar Impaction1st Molar Down FractureN/AOcclusal Plane Position Correction (mm)Maxillary MovementAdvancement/Setback MovementsAdvancementSetbackN/AAdvancement/Setback (mm)Left/Right MovementsPatient RightPatient LeftN/ALeft/Right (mm)Impact/Down MovementsImpactDownN/AImpaction/Down Fracture (mm)AccuPlan CMF ReconstructionSurgical Plan* Free Flap Reconstruction Trauma Reconstruction Resection Only (No Graft) Surgical Access Intraoral Extraoral Diagnosis Benign Malignant N/A Graft InformationGraft Data* Patient-specific Generic Fibula Selecting "patient-specific" graft site requires the submission of graft site CT data. Graft Site Anatomy*FibulaIliac CrestOtherGraft Side Patient Left Patient Right To be determined Additional Details Add Surgical Plan for Graft Planning Session duration may be improved with these additional details.Add Occlusal Data Set On Meeting Final Bite Provided Planning Dental Implants Yes No Predicted # of Graft SegmentsPedicle to Emerge Anterior Posterior Left Right AccuPlateAccuPlate Add Milled Titanium Plate (Locking Thread) Add 3D Printed Titanium (Non-Locking) Pre Bent Plate Screw Manufacturer Your case manager will confirm whether or not this manufacturer's thread is available for AccuPlate.Mandible Plate InstructionsAccuModelPlease describe anatomical area of interest.Model Selection (Orthognathic) Pre-op Mandible Pre-op Maxilla Post-op Mandible Post-op Maxilla Other None Please indicate additional Service Options. May incur additional cost. (Select all that apply.)Model Selection (Reconstruction) Pre-op Post-op Perfected Graft Template Other None Please indicate additional Service Options. May incur additional cost. (Select all that apply.)Model Selection (AccuShape) Skull Peri-defect (Host Bone) Model Implant Template Other None Please indicate additional Service Options. May incur additional cost. (Select all that apply.)Model Selection (AccuModel) Full Skull with Mandible Full Skull without Mandible Mandible & Maxilla (Fused) Mandible Maxilla Other None Other Model DetailsPlease describe the solution you need in detail.Comments Patient DataSubmission Method* Upload (Fastest) FedEx Already submitted Still waiting on scan Graft Site CT Data Acknowledgement* I acknowledge that by selecting "patient-specific graft data" for AccuPlan Reconstruction, I must submit patient-specific graft site CT data in addition to CMF CT data. CT Scan Date MM slash DD slash YYYY Shipping Add shipping information Shipping InformationAttention: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands HiddenUser Agent HiddenReferrer URL When completed, the Service Request will direct you to your chosen data transfer method.PHI Upload Consent* I agree to MedCAD's terms & conditions and privacy policy.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.
