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Form for inspection completed
Membrane for bone augmentation
1. Information about the doctor
Name:
Mob. Tel. No.:
E-mail:
2. Clinical case details
Patient's name, surname or other personal identification code:
Implants are planned:
Comment:
Provisional position of implant(s) according to FDI numbering
Before the bone augmentation procedure, removal of the tooth (teeth) is planned (enter FDI number):
Comment:
3. For evaluation and validation of the membrane design:
Selected
4. Providing information for planning
3D CT scan: attached
5. Information
Date of the operation:
Clinic name:
Shipping address: