Case Submission Form Dr. Name * Email * for case correspondence Phone (###) ### #### Preferred Contact Method Call Text Email PATIENT INFO Patient Name * First Name Last Name CASE INFO Select Arch * Upper Lower Dual Services Needed * Our full service All-On-X partnership includes the following items + digital design. Please select all that apply to this case. Smile Design Yomi Planning Photogrammetry Records Next Day Temp Milled Zirconia Final Mouth Guard Tooth Shade Guide Name * Tooth Shade * Surgery Date MM DD YYYY Additional Information Any other details about the case or your needs Thank you for submitting your case!Next Step: Upload Patient Records (photos, IOS scans, CBCT)Upload Patient Records HereThe VIV team will be reviewing the case and will reach out withany questions and to schedule services.We look forward to being your All-On-X partner!
