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KLS Martin IPS Data Upload Form

v2.1 (Nov. 2020)

* The KLS Martin IPS Data Upload Process uses a KLS Martin specific secured and encrypted Hightail upload link to protect patient privacy. After submitting the IPS Data Upload Form, you will be directed to the upload link.

Patient Info All fields required.

Contact Name

This field is required.

Contact Email (where IPS Plan will be sent by KLS Martin)

This field is required.

Patient Name

This field is required.

Hospital/Account Number

This field is required.

Surgeon Info All fields required.

Surgeon First Name

This field is required.

Surgeon Last Name

This field is required.

Surgery Date

This field is required.

Sales Rep

This field is required.

Case Type & Questions

Case Type

How will the dental models be provided?

Stone Models

Digital Dental Models (Intraoral Scanner, CT, etc.)

Unknown

At least one option is required.

Individual Models	Non-Segmental Maxilla	Segmental Maxilla
Pre-Op Upper	Required	Required
Pre-Op Lower	Required	Required
Post-Op Upper (Seg.)	N/A	Required
Final Occlusion	Optional	Optional

Will final occlusion be provided?

Yes

Please choose an option.

Will this be a segmental maxilla?

Yes

Please choose an option.

If so, be sure to include the pre-op maxillary dental model.

Distraction

Please provide preferred distractors. 2000 character limit max.

This field is required.

TMJ

Please indicate the case type

Orthognathic

Reconstruction

Please choose an option.

Please indicate what the data is for

Stage 1 (Initial Planning)

Stage 2 (Final Planning)

Please choose an option.

Will CT be provided?

Requested if previous scan date is not within 3 months of the surgery date or orthodontic movement has occurred.

Yes

Please choose an option.

Will dental models be provided?

Mandatory if models were not provided for Stage 1.

Yes

Please choose an option.

IPS Products

Splints

Implants

Guides

Please select at least one product or model.

Additional IPS Models

Select all applicable models to be requested, in addition to the standard models provided with associated IPS Implants or Guides.

Select all

Product Description

PEEK with holes, etc. 2000 character limit max.

This field is required.

Anatomical Region & Procedure

Left mandible repositioning, LF1 Distraction, etc. 2000 character limit max.

This field is required.

New Patient?

Yes

Other

Please choose an option.

If selecting 'Other', please add notes in the Additional Comments box.

If no, describe:

Previously completed case

Previously submitted active case

Other

Please choose an option.

Additional Comments

Anything else we should know? 2000 character limit max.

This field is required.

Before you download the Patient Case Form, please verify that all the information is correct.
Please send planning order forms to reduce time and input needed during the web meeting.

Forms: