NavaGation Jotform Update

NavaGation Guided Surgery & Latched Conversion

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

First NameLast Name
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.

Other
Practice Branch
Please include location
Phone Number

Area CodePhone Number
I'm submitting
Please Select the Working Arch or Arches
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?
How did you find us?

Other
License #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records

Other
Upper Case Type
Please note: Selecting the incorrect arch will result in a fee for completed work. This may include planning and model costs.
Lower Case Type
WARNING: Selecting "None" for upper and lower case type will require clarification with your office and may delay your case
Please note: Freehand cases using a same-day prosthetic workflow require a 5-10 business days for pre-design workup.

A minimum of five business days is required to process a pre-design workup.

A rush fee of 25% will apply to same-day cases requiring a turnaround shorter than five business days.

Submitting records without a scheduled date may cause a scheduling conflict and may incur a rush fee.

Same day design slots can not be reserved before records are recieved, as available slots fill up quickly.
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 below if you have already filled out the consent form:
Please upload consent form here:

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See our scanning protocol here
Please DO NOT include the patient name in any uploaded file names.
Dicom
DICOM Upload (Out of Occlusion)

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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
Upper Scan STL

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Lower Scan STL

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Bite Scan STL

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Models for Partially Edentulous Cases
Upper Scan Without Partial STL

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Lower Scan Without Partial STL

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

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Bite Scan STL (with partials if applicable)

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Denture or Scan Appliance Scan
Denture Scan(s) (.stl or dual-scan)

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STL Guide (s)

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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
Photographs - Retracted | High and Low Smile| Profile

Upload Files
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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
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
Scanner
Photogrammetry Scanner

Other
IO Scanner

Other
Note - we can only accept scans completed with the OEM scan flags verified for your scanner.
Scan Body
Screw
Please text (919) 519-1900 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
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
Once submitted, please wait until you see a 'Thank You' screen
Should be Empty:

NavaGation Guided Surgery & Latched Conversion