Smile in a box

Are you a registered customer of "Smile in a Box"? *

Yes No
Please submit your information and Straumann will contact you shortly
Customer Name *

First Name Last Name
Customer e-mail Address *
Company Name

Shipping Address *

Street Address

City	State/ Province
Zip Code	Country

Phone Number *

- Country Code Phone Number
Straumann customer number
1. Patient Information
Patient full name/ Case reference number *
Condition & Treatment scope *
Additional clinical observation
2. Implant configuration
Brand *
Other
Please specify if you use another implant
Platform *
Height
Surgical Kit
Other
Please specify if you use another surgical kit
Case type *

Single Multiple units Full arch edentulous
Number of implants
Preferred alignment
Other
Numbering System *
Please select a numbering system to be able to indicate the implant sites.

Preferred guided surgery solution *

Sequential pin-supported solution Stackable solution
3. Prosthesis design
Would you like to order a temporary restoration? *

Yes No
Coloring/ Shades *
Will you provide a mock-up of the temporary? *

Yes No
Additional instructions
Smile design (instructions regarding midline, VDO, overjet, esthetics, phonetics, etc.)
4. Workflow Planning & Form Submission
Additional services

Custom tray Scan appliance Backup denture Surgical guide try-in Anatomical model
Preferred treatment plan review method *

INTERACTIVE: Straumann will contact you to schedule an online meeting to review and adjust the plan prior to submitting the report (mandatory for full arch restoration). DOCUMENT-BASED: Straumann will submit a report for you to review and approve.
IMPORTANT NOTE ON SURGERY SCHEDULING

Our design and manufacturing turnaround is 10 business days, initiated following the approval of the final plan by the clinician.As case initiation (submission and lab processing) turnarounds are less predictable, we highly recommend to schedule the surgery after submitting the treatment plan approval.
Planned Surgery Date ( if known, see above)

- Año - Mes Día
Please upload your files here:

Browse Files
Please note that the maximal file size is 1 Go for single file upload and 100 Mo for multiple files upload. Please upload CT scans in .zip format. Cancel of
If your files cannot be uploaded, please provide a link to a cloud storage (dropbox, box, drive, hightail, etc.):
Signature *

Clear
Please wait for the confirmation prior to navigating away from this page. Upon successful submission, you will also receive an e-mail confirmation including a copy of the submitted Rx, attached in PDF format.
Should be Empty:

1. Patient Information

2. Implant configuration

3. Prosthesis design

4. Workflow Planning & Form Submission

IMPORTANT NOTE ON SURGERY SCHEDULING