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MedCAD Service Request V4

Step 1 of 5

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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
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  • Case Information

  • MM slash DD slash YYYY
  • Select Products

  • AccuShape® Cranial Implant

  • Please indicate drainage hole preference. (Select one)
  • Please indicate additional Service Options. May incur additional cost. (Select all that apply.)
  • AccuPlan® TMJ Planning

  • Please indicate add-on services here. May incur additional cost. (Select one or more)
  • AccuPlan® Orthognathic Planning

    Patient-Specific Orthognathic Surgical Planning
  • Orthognathic Notice!
    To begin a case, MedCAD needs all of the following items:
    • CT Scan
    • Stone 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 Plan

    Please indicate area(s) of interest.
  • Maxilla Plan

  • Please enter a number from 1 to 5.
  • Mandible Plan

  • Occlusion & Options

    Note: defining surgical movements now may speed up your planning session experience
  • Surgical Movements

  • Landmark indicating focus of correction.
  • Please enter a number from 0 to 30.
  • Please enter a number from 0 to 30.
  • Maxillary Movement

  • AccuPlan® Reconstruction

    Surgical Planning for Oral-Maxillofacial Reconstruction
  • AccuPlan CMF Reconstruction

  • Please indicate add-on services here. Select one or more.
  • Graft Plan

    Selecting "patient-specific" graft site requires the submission of graft site CT data.
    Planning Session duration may be improved with these additional details.
  • AccuModel® 3D Anatomical Model

  • Additional Notes

  • AccuPlate

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

  • MM slash DD slash YYYY
  • :
  • 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.
    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.
  • Submission

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • What method did you use to send the data for this case?
  • Quick Links
    CMF CT Scanning Protocol
    CT Upload Instructions
  • Shipping Information

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    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 being 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.
    I Have Read MedCAD Data Privacy Policy And The Above Information.
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