Case Submission Form Dr. Name * Email * for case correspondence Phone (###) ### #### Preferred Contact Method Call Text Email PATIENT INFO Patient Name * First Name Last Name CASE INFO Select Arch * Upper Lower Dual Services Needed * Our full service All-On-X partnership includes the following items + digital design. Please select all that apply to this case. Smile Design Yomi Planning Photogrammetry Records Next Day Temp Milled Zirconia Final Bite Splint Tooth Shade Guide Name * Tooth Shade * Target Surgery Date, if applicable Date to be confirmed after case review. If surgery has already been completed leave this blank. MM DD YYYY Additional Information Any other details about the case or your needs (ex: any other target dates we need to be aware of, screw preferences, existing prosthetics and/or implants, etc) Thank you for submitting your case!Next Step: Upload Patient Records (photos, IOS scans, CBCT)Upload Patient Records HereThe VIV team will be reviewing the case and will reach out with any questions and to schedule services.We look forward to being your All-On-X partner!
