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1. Information about the doctor

Name:

Mob. Tel. No.:

E-mail:

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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:

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3. For evaluation and validation of the membrane design:

Selected

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4. Providing information for planning

3D CT scan: attached

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5. Information

Date of the operation:

Clinic name:

Shipping address:

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Confirm your order