Form

Please complete the Start a Case form below. Please be as detailed as possible. Each case includes a tube guide, an EndoFile with a fitted stop, and custom drill stops. Please refer to our protocols and call with any questions: 855-484-3335. * represents a mandatory field for completion.
Patient Name *
Email *
Surgery Date *

- Month - Day Year
Date
Minimum Incisal Opening (mm)
How do you plan on performing the surgery? *
Explain any procedures which may alter patient anatomy before surgery
Would you like us to plan your treatment (with review session)? *

Yes ($150 to $325 based on complexity) No
What days and times would be best for a 15-minute case review?
Also list names and emails of others you would like to invite to the review
Surgery
What handpiece will you be using for the case? *
Be as specific as possible. If GSS already has your handpiece information, please type “On File”.
STEPPED DRILLS: You may use your current drills (select below) or try/buy a set of five special drills optimal for guided surgery; for more information, click the link below. Check one of the following: *

I like these Guided Surgery stepped drills! Please send me new drills with my case and invoice me for them** I want to use the “try-to-buy” GSS Loaner Program for this case free of charge (first case only) Not this time
See more information about our Guided Surgery Stepped Drills here.
Which drills will you use? *
Please indicate if we have not measured them. Skip if you’ve selected STEPPED DRILLS.
Please list the following for each surgical site: Tooth #, Implant system, Implant diameter and length *
1) This information can be changed until your final approval of the surgical guide. 2) We do not provide bone screws or related instrumentation. If you plan to use bone screws, please specify the size and placement. Guided Surgery Solutions recommends purchasing bone screws from Salvin.
What is the Final Prosthetic Goal? *
For improved visibility and access please add a ThinLayer TUBELESS guide for this case. *

Yes No
Tubeless Guide: The ThinLayer Guided Surgery System includes a proprietary tube guide, custom drill stops and endofile/stop. The ThinLayer TUBELESS Drill Guide provides additional access, visibility and intra-operative flexibility particularly for challenging cases; for more information, click HERE. – Additional Cost
Any planning services requested will be billed at rates derivative of guide pricing should the guide not be produced and shipped within 2 months of authorization. For guide pricing, click HERE.
Is this your first case with Guided Surgery Solutions? *

Yes No
Approve and Submit
By signing or initialing this order, I hereby approve and submit this Work Authorization. The referenced Signatory Dentist (“Dentist”) represents, declares and agrees that the Dentist (1) is a licensed dental professional qualified to perform the dental implant procedure documented in the related case plan; (2) has reviewed the case plan and all relevant data related to the case plan and approve the same; (3) that the file and all relevant data provided to Guided Surgery Solutions, LLC and its subcontractors (collectively “Company”) for purposes of constructing the surgical guide is accurate and approved by the Dentist; (4) agree that Company is not responsible for improperly fitting surgical guides when related stone models are not available; (5) assumes full responsibility for both the plan and resulting surgical guide(s); and (6) that this Work Authorization is being made subject to the terms of the Master Surgical Guide Agreement which includes, but is not limited to, disclaimers on all warranties and a limitation of Company’s liability. By submitting this Work Authorization, the Dentist is commissioning Company to obtain or construct the surgical guide(s) and accepts all terms and conditions established by the surgical guide manufacturer and Company.
Next Steps (see website for further information)
1. Upload the scan files to Dropbox
2. Depending on the protocol you’re following, please mail all required items to the address below:
Please provide any additional requests (ex: alternate shipping/billing information than what we have on file)
If you have multiple office locations, please specify where you would like your surgical guide to be shipped.
Name (e-signature) *
License # *
Date *

- Month - Day Year
Date
Thank you for your order, please call us at (855) 484-3335 with any questions
Guided Surgery Solutions, LLC 1 Washington St, Ste 106 Wellesley, MA 02481
Are you a Lab? Please use this form instead.
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Surgery

Approve and Submit