Cagenix | Cagenix Smile Freely

Cagenix Smile Freely Case Nomination Form

Our mission is to create innovative, full-arch dental restorations proven to give your patient a smile they will want to share with the world. The Cagenix Smile Freely program was established for patients who due to unfortunate economic circumstances would not be able to receive treatment without the help of Cagenix donating their products.

Nominate a patient by November 22, 2022, to receive a free full-mouth or full-arch restoration from Cagenix. We will select the patient and announce the winner in December. Treatment can occur any time by December 31, 2023.

Cagenix will select a patient who we feel will benefit the most from this donation. The patient will be selected based on the information provided in this form.

Practice Information Clinician Name: Email: Practice Name: Address: City: State: Zip Code: Clinician Phone:

Patient Information Patient Age: Patient Sex:

Male
Female
Other/Non-Binary

How will the Cagenix Smile Freely program change your patient's life? Please provide a brief summary of the patient’s unfortunate economic circumstance that places them in need.  NOTE:  Please do not include patient name. When could the surgery be scheduled?

30 days
30 - 60 days
60 - 90 days
> 90 days

CONDITIONS FOR CASE SUBMISSION

In return for Cagenix providing the final restoration at no charge, the practitioner agrees to provide the following items:

Case images including before and after intra oral images of the Cagenix restoration
Description of the patient: age, sex, (non)smoker, any systematic diseases, patient history.
Treatment outcome from the patients point of view (potentially participate in a testimonial video and/or photography with the patient)
Testimonial from treating clinicians about Cagenix restorative solutions as a practice differentiator

Each Practitioner individually represents and warrants that he or she has obtained a legally valid waiver and consent from the patient to use the images in connection with this case contest. A copy of that consent is hereby attached.

ASSIGNMENT OF RIGHTS

The Practitioner(s) grant and herewith irrevocably assign to Cagenix the worldwide, non-exclusive, royalty free right to publish the Case Documentation. The foregoing grant and assignment of rights includes but is not limited to the use of the Case Documentation as often as desired in all media for purposes of lectures, presentations and broadcasting, and for the production and distribution of print, audiovisual and electronic reproductions.

Cagenix collects your information to evaluate the eligibility of the case submitted and facilitate the support of the case if selected. Please see our Privacy Policy for more information.