PATIENT NAME:______________________
DENTIST NAME:__________________________
TREATMENT PLAN:
[] Single tooth
[] Fixed partial denture
[] Over-denture
[] Fixed complete denture
[] Maxilla
[] Mandible
[] Both Jaws
IMPLANT SYSTEM: [] NobelBiocare []
ITI [] Others:_______________
IMPLANT LOCATION:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31
30 29 28 27 26
25 24 23 22 21 20 19 18
17
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| DIAGNOSTIC: | |||
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FMX
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Panoramic
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CT scan
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Radiographic Stent
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Study models
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Wax-up
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Surgical Guide
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| PROVISIONAL PROSTHESIS | |||
| SURGICAL FEES: | |||
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Extraction(s)
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Bone augmentation
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Sinus grafting
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Implant
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Intravenous sedation
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Implant indexing
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Soft tissue augmentation
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Second Stage surgery
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| PROSTHESIS MAINTENANCE | |||
| RESTORATIVE COMPONENTS | |||
| ABUTMENT CONNECTION | |||
| FINAL PROSTHESIS | |||
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SUB TOTAL
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GRAND TOTAL
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