Submit a request – Southern Implants

Your email address

Subject

Surgery date

Please remember that we need 14 WORKING days from submission of the order to the surgery date

Patient reference

Name of clinician:

Telephone number: (optional)

Southern Implants account number

Are you supplying us with digital files or an impression?

If you are providing digital files, please upload your DICOM and STL files in the box provided below. If you’re sending us an impression(s), please send it to: SI Guided | Southern Implants UK | Suite 224, Building 3, Chiswick Business Park | London | W4 5YA NOTE: PLEASE USE A PUTTY WASH FOR ANY IMPRESSIONS. ALGINATE IMPRESSIONS SHOULD BE AVOIDED.

Please select the service required

Please note the following timeframes: SIGuided resin guide: 14 working days from submission | SILoaded full arch metal guides - 6 weeks after approval of plan | SI Loaded stackable resin options - 6 weeks from submission of case

Is this surgery pilot or fully guided?

Tooth number(s):

Implant system

Other systems(optional)

If you selected another system, please let us know your preference

Are you planning to use co-axis if suitable?

Please select which of the following components are required(optional)

Please select the drills required from the options below:(optional)

Lab services(optional)

Please select from the following services if required

If ordering a temporary crown, please let us know the shade here: (optional)

Essex retainers additional information (optional)

If an Essix retainer is requested, please provide us with more information. (do you need teeth in them, do you want them blown over the original teeth or over a wax-up model, etc.)

Your prescription

Please enter the details of your case and any information that will help us plan the case effectively.

Attachments(optional)

Add file or drop files here