Order Guide
On Target Surgical Guide Order Form
Planning and Manufacturing Service for the On Target Surgical Guide provides:
• Surgical plan based on clinician information
• Surgical protocol
• Surgical guide for surgical phase of treatment
Please allow 10 days for the planning and manufacturing of the surgical guide.
I acknowledge that the responsibility for clinical data collection, decision making, and implementation lies solely with the clinician. Responsibility of clinical outcomes does not lie with the AuDentes service, nor its owners, associates, staff or affiliates at any time.
Surgeon Name
Mobile
Email
Phone
Address
Preferred Contact Method
Mobile
Phone
Email
Patient Name
Patient Date of Birth
Gender
Male
Female
Date of Surgery
Required Date
Hospital
Delivery Address
Type of Guide
Teeth & Tissue Supported Guide
Teeth & Bone Supported Guide
Bone Supported Guide (Edentulous Patient)
Type of Drill Sleeve
Fully Guided
Pilot Drill System
Tooth Number (Implant Location)
Implant Brand & Model
Diameter
Length
Tooth Number (Implant Location)
Implant Brand & Model
Diameter
Length
Tooth Number (Implant Location)
Implant Brand & Model
Diameter
Length
Tooth Number (Implant Location)
Implant Brand & Model
Diameter
Length
Notes
Upload the below files to Dropbox and share with
plans@audentes.com.au
Select all that apply:
CBCT (DICOM)
Intraoral scans (STL)
Photos
Data has been sent via coDiagnostiX
Submit
