Dental Implant System – Case Record Form (Diagnosis / Surgery Report)

1. Clinic / Practice Information

① Name and address) *

② Treating doctor *

③ Treatment on: *

1.2 Patient information

Gender *

female male

Age *

3. Product Information

#	Implant	Ø	Length	Regio	LOT-No.
1
2
3
4
5
6
7
8
9
10
11
12

#	Prosthetics / Abutment	Regio	LOT-No.
1
2
3
4
5
6
7
8
9
10
11
12

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Dental Implant System – Case Record Form (Diagnosis / Surgery Report)

1. Clinic / Practice Information

1.2 Patient information

2. Medical History

3. Product Information

4. Surgery / Treatment

5. Prosthetic Phase

6. Radiographic Diagnostics

1. Clinic / Practice Information

1.2 Patient information

2. Medical History

2.1 Indication & Diagnosis – Basic indication

2.2 General health status

3. Product Information

3.1 Implant

3.2 Prosthetics / Abutment

4. Surgery / Treatment

4.1 Surgical technique / course of surgery

4.2 Site preparation & stability

5. Prosthetic Phase

5.1 Immediate loading

5.2 Exposure

5.3 Prosthetics

6. Radiographic Diagnostics

6.1 Preoperative X-ray

6.2 Intraoperative X-ray

6.3 Postoperative X-ray

6.4 Prosthetic phase