Service Request 3.0 "*" 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: 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 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* AccuShape AccuPlan TMJ AccuPlan Orthognathic AccuPlan CMF Reconstruction AccuModel Other 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. AccuShapeDrainage Holes* Standard None Other Edge Type* Standard Edge (Default) Overlap Edge Other Additional Holes Include fixation holes Other Customization*AccuPlan TMJ PlanningTMJ Surgical Plan* Patient Left Patient Right Include Orthognathic Planning TMJ Planning SpecificationsAccuPlan Orthognathic PlanningOrthognathic Surgical Plan* Upper Jaw Lower Jaw SequenceMandible FirstMaxilla FirstMaxilla PlanMaxilla Le Fort*Le Fort ILe Fort IILe Fort IIIMaxilla Le Fort Confirmation*Le Fort IILe Fort IIILe Fort II's and III's are uncommon, please verify this is accurate. Maxilla Segments*Mandible PlanMandible Surgery (Left Side) Sagittal Split Osteotomy (SSO) Vertical Ramus Inverted L Subapical Osteotomy Other N/A Mandible Surgery Genioplasty Mandibular Split Other N/A Mandible Surgery (Right Side) Sagittal Split Osteotomy (SSO) Vertical Ramus Inverted L Subapical Osteotomy Other N/A Other Mandible SurgeryOcclusion & OptionsDental Data Supplied by Customer* Digital occlusal data (stone model scan or intraoral scan) Physical Stone / 3D Printed Dental Models Dental data is required for Orthognathic planning. This can be uploaded or shipped directly to MedCAD.Final Occlusion* Use surgeon-supplied final occlusion I want MedCAD to digitally set the final occlusion Dental Splints Final Splint Intermediate Splint Dome Splint Palatal / Horseshoe Splint Sandwich Final / Intermediate Splint Include Duplicates Other N/A Additional Details Add Clinical Measurements Add Planned Surgical Movements Planning Session duration may be improved with these additional details.Clinical MeasurementsMaxillary Dental DeviationRightLeftMaxillary Dental Deviation (mm)Current Occlusal Plane AngleCanine PositionLeft SuperiorRight SuperiorEvenCanine Position (mm)Planned 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 CrestScapulaOtherOther Graft Site Anatomy Graft 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.Graft Height Above Inferior Border (mm)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 borderPredicted # of Graft SegmentsPedicle to Emerge Anterior Posterior Left Right AccuPlateAccuPlate Add patient-specific mandible plating May incur additional cost. Screw Manufacturer* Your case manager will confirm whether or not this manufacturer's thread is available for AccuPlate.Mandible Plate Thickness2.0mm2.6mm2.8mmMandible Plate InstructionsAccuModelPlease describe anatomical area of interest.Model Selection (Orthognathic & TMJ) Pre-op Mandible Pre-op Maxilla Post-op Mandible Post-op Maxilla Other None May incur additional cost. Model Selection (Mandible Reconstruction) Post-op Mandible (with graft) Pre-op Mandible Graft Template Post-op Mandible (perfected contour) Post-op Mandible (trauma repositioning) Post-op Mandible (resectioned without graft) Other None May incur additional cost. Model Selection (AccuShape) Full Skull with Mandible Full Skull without Mandible Peri-defect (Host Bone) Model Implant Template Other None May incur additional cost. 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.Privacy Policy* I agree to the privacy policy.Terms and Conditions* I agree to the terms and conditions.
