NavaGation Jotform Update

NavaGation Guided Surgery & Latched Conversion

1-844-NAVAGAT (628-2428)
Restorative Dr.*

First NameLast Name
No Surgeon
Surgeon*

First NameLast Name
If there is a surgery/appointment date scheduled, please include it here. Please note, we guarantee shipment of a Synergy case 10 business days after review and approval (allow 2 additional business days for shipping). We do not suggest scheduling a surgery date until you have approved the case.

Not scheduledOther
Practice Branch
Please include location
Phone Number*

Area CodePhone Number
I'm submitting*

New CaseAdditional Materials for an Existing CaseA Pre-Planning Consent Form OnlyA Chairside Consent Form Only
Please Select the Working Arch or Arches*

UpperLower
Please DO NOT include the patient name in the Patient Identification Code.
Patient Identification Code (PIC) *
Required for case communication to maintain HIPPA compliance. Please enter existing PIC (already used within your office). Or Create a 5-7 digit code (alpha & numerical) Example: Pt. John Doe = D13578
Need a unique PIC? Feel free to copy and paste this one below:
Patient Name (Not Required)

First NameLast Name
Care Coordinator

First NameLast Name
Primary Email*
example@example.com
Care Coordinator or Secondary Email*
example@example.com
Restorative Email
example@example.com
Please note: These are the only emails that will be used for correspondence
Is this your first case with us?*

YesNo
How did you find us?

ReferralImplant RepStudy ClubSocial MediaNavaGation RepOther
License #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records*

Records for a Dentate PatientRecords for an Edentulous PatientRecords for a Partially Edentulous PatientPatient Photos Only (Required for all full-arch cases)Already designed surgical guide to be printed, sleeved, and returnedRecords for a Phase IIPre-Operative records for AoX Same Day Case DesignOther
Upper Case Type*
Lower Case Type*
WARNING: Selecting "None" for upper and lower case type will require clarification with your office and may delay your case
I have read and understand
Please note, a Planning and Review Consent Form must be on file for every customer. Please download, fill out, and submit the form below:

Please check here if you have already filled out the consent form
Please upload consent form here:*

Browse Files

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See our scanning protocol here
Please DO NOT include the patient name in any uploaded file names.
Dicom*

Uploading DICOMSending physical mediaUploading DICOM with Radiographic MarkersContact another office for DICOM
DICOM Upload (Out of Occlusion)*

Browse Files
Please upload a zipped folder of raw .DCM slices. Please do not include special characters in the file name, eg. "$,%,*,#,@" Cancelof
See our Phase II protocol here. Note that at this stage the only required scan is a 360° scan of the restoration with scan flags in place. If the scan flags do not seat fully, please give us a call. Thank you!
Model*

Uploading Models on WebUploading via SironaUploading via IteroUploading via TriosUploading via Dexis ConnectUploading via CS ConnectUploading via EndossierUploading via MeditSending Stone Models or ImpressionsContact another office for Models
Upper Scan STL*

Browse Files

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Lower Scan STL*

Browse Files

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Bite Scan STL*

Browse Files

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Models for Partially Edentulous Cases*

Uploading Models on WebUploading via SironaUploading via IteroUploading via TriosUploading via Dexis ConnectUploading via EndossierUploading via MeditContact another office for ModelsUploading via CS ConnectPatient does not have a stable biteSending Stone Models or Impressions
Upper Scan Without Partial STL*

Browse Files

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Lower Scan Without Partial STL*

Browse Files

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Model(s) with Partial STL (with radiographic markers)*

Browse Files
ctrl+click or shift+click to select multiple files Cancelof
Bite Scan STL (with partials if applicable) *

Browse Files

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Denture or Scan Appliance Scan

CBCT Dual-Scan with radiographic markersDigital scan with radiographic markersContact another office for Denture ScanSending a duplicate denture / scan appliance, with radiographic markersThe patient does not have a well-fitting dentureN/A
Denture Scan(s) (.stl or dual-scan)*

Browse Files
ctrl+click or shift + click to select multiple files Cancelof
STL Guide (s)

Browse Files
ctrl+click or shift + click to select multiple files Cancelof
We can manufacture wax bite rims for jaw relation records. Please include models of the working arch or arches.

Please request bite rims in the notes below

Please contact us at 1-844-NAVAGAT (628-2428) with any questions.
Pt. Photographs

Uploading PhotosSending Physical MediaContact another office for PhotosN/A
Photographs - Retracted | High and Low Smile| Profile

Upload Files
ctrl+click or shift + click to select multiple files Cancelof
Contact Email*

Confirmation Emailexample@example.com
Contact Office*
WARNING: The contact email for another office is the same as your primary or secondary email
Phone Number*

Area CodePhone Number
Tracking Number
a tracking # will be on our return shipping labels
Record Locator #
may be 'ID' or 'case number' depending on software
Implant/Abutment Brand*
please note any atypical sites (such as fixture level) below
Scan Flags*
Prevu Smile Sim

Not neededYes - Please note: this will require a full-face photo with a natural smile. The working arch should be visible.
Please note: a smile sim will not be completed until patient photos are provided
Shade
Guided Kit*
Tissue Shade*
Implant Supplier Acct. #*
we will order components on your account
Implant Brand*
AoX Same Day Case Design Information
Printing*

In-office printingPrint-and-ship from lab
Scanner*

Using a handheld IO scanner at surgeryUsing a photogrammetry scanner at surgery
Photogrammetry Scanner*

Itero [Lumina Only]DexisSirona [Primescan Only]Trios [4/5/6 Only]MeditSHINING3dOther
IO Scanner*

AoralscanPICICAMMicronMapperTupel 3d (Grammee)Other
Note - we can only accept scans completed with the OEM scan flags verified for your scanner.
Scan Body*
Screw*
Please text 984-317-1889 for Day-of-Surgery communication
Please refrain from scheduling a surgical date when requesting chairside support. Chairside support may not be available on an already scheduled surgery date.
Clinical Support

Chair side supportI'd like chair side support, and I've already filled out the formNo chair side support
I accept that chairside support may not be available for a scheduled surgery date, we request waiting to schedule the patient until after case review and approval
Please fill out and upload the form below, keep a copy for your records:
Please upload here:*

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Implant Sites*
Please DO NOT include the patient name in case notes.
Additional Notes*
Agree to terms and conditions of order*

I have read, understand, and agree to the terms and conditions of ordering products using this form.I understand that a NavaGation case cannot start until all necessary records are provided. A cancellation fee will be applied for work already completed at time of cancellation.
Once submitted, please wait until you see a 'Thank You' screen
Should be Empty:

NavaGation Guided Surgery & Latched Conversion