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MedCAD Service Request

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Please complete the following service request to begin your case. Press Next to continue.

Important Notes:
- CMF CT/CBCT Scanning Protocol - Please make sure your CT submission meets our CT protocol.
- Please do not enter any patient names on this form.
- If you require immediate assistance, please call (214) 453-8864.
MEDCAD TEAM
Please acknowledge before proceeding*
- To ensure the timely processing of your case, it is essential to submit a complete service request along with the required patient scan. Please coordinate with relevant parties to gather all required information for submission. Incomplete submissions may result in delays. Thank you for your attention to this matter and for helping us provide the best possible service
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Case Number
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User Role

Case Information
Your Role
Other Role*
Company*
Your Name*
First Last
Your Mobile Phone*
Your Email*
Surgeon*
First Last
Surgeon Email
Sales Representative
First Last
Hospital*
Surgery Date
- Not Scheduled
Scheduled Surgery Date*
MM slash DD slash YYYY
Select Products
MedCAD Patient-Specific Products*
- Cranial Implants - AccuShape
- CMF Reconstruction - AccuPlan
- Orthognathic - AccuPlan
- 3D Anatomical Model - AccuModel
- TMJ Planning - AccuPlan
- Other / Not Sure

AccuShape® Cranial Implant
Material Options*
- PEEK
- Titanium
Drainage Holes*
Please indicate drainage hole preference. (Select one)
- Include holes
- No Holes
- Other/Not Sure
Add-On Services
Please indicate additional Service Options. May incur additional cost. (Select all that apply.)
- Implant Template Model
- Peri-Defect (Host Bone) Model
- Browse more AccuModel options
Edge Type*
Custom Edge Specification*
AccuPlan® TMJ Planning
TMJ Planning for*
- Patient Left
- Patient Right
Details
Additional Services
- Include Orthognathic Planning
AccuPlan TMJ - Models
Please indicate add-on services here. May incur additional cost. (Select one or more)
- Pre-Op Mandible Model
- Pre-Op Maxilla Model
- Post-Op Mandible Model
- Post-Op Maxilla Model
- Other
AccuPlan® Orthognathic Planning
Patient-Specific Orthognathic Surgical Planning
Orthognathic Notice!
To begin a case, MedCAD needs all of the following items:
- CT Scan
- Stone models & Bite index (OR Intraoral Scan)
- Service Request OR Order Form
If you are sending stone models you may continue with this service request or complete the physical form and send case requirements to 501 S 2nd Ave. Ste A-1000, Dallas, TX 75226.
If you are sending intraoral scans, please proceed with this service request.
Surgical Plan
Surgical Plan
- Mandible
- Maxilla
Please indicate area(s) of interest.
Maxilla Plan
Maxilla LeFort*
- LeFort I
- LeFort II
- LeFort III
Maxilla Segments*
Please enter a number from 1 to 5.
Mandible Plan
Mandible Surgery (Left Side)
- Sagittal Split Osteotomy (SSO)
- Vertical Ramus
- Inverted L
- Subapical Osteotomy
- Other
Mandible Surgery (Right Side)
- Sagittal Split Osteotomy (SSO)
- Vertical Ramus
- Inverted L
- Subapical Osteotomy
- Other
Mandible Surgery
- Genioplasty
- Mandibular Split
- Other
Mandible Plan - Other*
Occlusion & Options
Final Occlusion*
- I will send Final Occlusion Stone Models
- I want MedCAD to digitally set the Final Occlusion
- N/A
Surgical Movements
- Define Surgical Movements Later in the Planning Session
- Define Surgical Movements Now
Note: defining surgical movements now may speed up your planning session experience
Add Anatomical Models
- Yes
Model Selection (Orthognathic)
- Pre Op Mandible
- Pre Op Maxilla
- Post Op Mandible
- Post Op Maxilla
- Other
Other Details
Surgical Movements
Midline Correction
Landmark indicating focus of correction.
Midline Correction (mm)
Occlusal Plane Angle Correction
Occlusal Plane Angle Correction (degrees)
Please enter a number from 0 to 30.
Occlusal Plane Position Correction
Occlusal Plane Position Correction (mm)
Please enter a number from 0 to 30.
Maxillary Movement
Advancement/Setback
Advancement/Setback (mm)
Impaction/Down Fracture
Impaction/Down Fracture (mm)
AccuPlan® Reconstruction
Surgical Planning for Oral-Maxillofacial Reconstruction
AccuPlan CMF Reconstruction
Surgical Plan*
- Free Flap Reconstruction
- Trauma Reconstruction
- Resection Only (No Graft)
Surgical Access
Diagnosis
Add Occlusal Data
- Set On Meeting
- Final Bite Provided
Add Anatomical Models
- Yes
AccuPlan Recon - Models
Please indicate add-on services here. Select one or more.
- Pre-Op Anatomical Model
- Post-Op Anatomical Model
- Graft Site Anatomical Model
- Other
AccuPlan Recon - Models - Other
Planning Dental Implants
- Yes
- No
Graft Plan
Graft Data*
- Patient Specific
- Generic Data
Selecting "patient-specific" graft site requires the submission of graft site CT data.
Graft Site Anatomy*
Graft Side
Acknowledgement*
- I will send patient graft data to MedCAD (i.e. CT of fibula)
Additional Details
- Add Surgical Plan for Graft
Planning Session duration may be improved with these additional details.
Predicted # of Graft Segments
Pedicle to Emerge
- Anterior
- Posterior
- Left
- Right
AccuModel® 3D Anatomical Model
Model Options*
- Skull With Mandible
- Skull (No Mandible)
- Maxilla & Mandible (Fused)
- Maxilla
- Mandible
- Other
Other Model Details
Additional Notes
Additional Notes
AccuPlate
AccuPlate
- Add Milled Titanium Plate (Locking Thread)
- Add 3D Printed Titanium (Non-Locking)
- Pre Bent Plate
Screw Manufacturer

Your case manager will confirm whether or not this manufacturer's thread is available for AccuPlate.
Mandible Plate Instructions

Planning Session
Planning Session
- Request Meeting Now
- Contact Me to Schedule
- Not Sure
- N/A
Requested Planning Session Date
MM slash DD slash YYYY
Requested Planning Session Time

: Hours

Minutes

AM/PM
Surgeon Time Zone*
Note! Most cases require at least 24 hours between the approval of all input and the Planning Session. By requesting a meeting, we do not guarantee the meeting time will be available though we will do our best to accommodate. For additional support, please contact your Case Manager at +1 (214) 453-8864 x 1.
Submit SR
- Yes
Select Yes if you are ready to submit the service request as an order for products. Once Yes is selected, you may press the "next" button below to submit.

Submission
Submit Data*
- Upload CT (Recommended)
- FedEx CT
- Already Submitted CT
- Waiting on CT
CT Scan Date*
MM slash DD slash YYYY
Expected CT Date*
MM slash DD slash YYYY
Patient Initials*
Submission Method*
What method did you use to send the data for this case?
Tracking Number
Also submitting:*
- Intraoral Scan
- Stone Models
- Bite Index
Quick Links
CMF CT Scanning Protocol
CT Upload Instructions
Shipping Information
- Click here to add shipping information.
Shipping Information
Attention:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Terms & Conditions and Privacy Policy
Consent*
I agree to MedCAD's terms & conditions and privacy policy.
MedCAD is compliant with Health and Human Services (HHS) requirements for HIPAA / HITECH including 45 CFR Part 160 and Part 164, as well as the HITECH Act.
MedCAD is committed to employing all methodologies and technologies available to protect the PHI we are entrusted with.

For digital data transfer, a secure web portal is being employed as a method of communication that prevents unauthorized parties from being able to access or read any content while it is in transmission. I understand the risks associated with online communications, and I consent to the conditions outlined in the MedCAD Data Privacy Policy. In addition, as a Business Associate, I agree that I have obtained authorization from the Covered Entity to share PHI for a given purpose.
I Have Read MedCAD Data Privacy Policy And The Above Information.
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+1 (214) 453-8864

501 S. 2nd Ave., Suite A1000,
Dallas, TX 75226

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