Skip survey header

Let Them Shine Application_United States

* LET THEM SHINE CASE SUBMISSION *

 

Case Submission Form

Instructions
For your patient to be considered for support through Let Them Shine, please complete this application in its entirety. Be as detailed as possible about the case and the circumstances of the proposed patient.

Patient Criteria:

Let Them Shine was established for patients who, due to unfortunate economic circumstances, would not be able to receive implant treatment without the help of the clinician and Straumann Group donating their services, time, and products, and generous monetary donations made by the employees of the North America Straumann Group companies.

On a quarterly basis, the Let Them Shine Selection Committee will choose several transformational cases for patients who, based on the applications received, will benefit most from the donated procedures. The information provided in this form will provide the basis for the review of patient cases, and selection of these transformational cases will be based upon patients chosen during the review process and the amount of donations available in the Let Them Shine fund. (Transformational cases include those that significantly impact functionality, smile and/or confidence.)

Because telling the story of the transformation afforded by this program is critical to helping us inspire donations and helping other patients see the transformational effects of implant procedures, all patients chosen must be willing to share before and after photos showing their smile (without other identifying characteristics) as well as a written testimonial or letter about their experience with the surgical procedure and Let Them Shine, and highlight the impact both had on their life. The photos and testimonial/letter will be used to promote Let Them Shine and to create a separate case story to be used to highlight the benefits of implant procedures for other patients.

  1.  In addition, we choose some cases to be told through video in a documentary-style format that helps raise funds for Let Them Shine and inspire other patients to seek implant treatment. If chosen and patient agrees, accepted patients must be willing to be photographed and participate in video interviews and video shoots at their home, work, etc., before and after surgery and following final restoration to chronicle their oral health journey and Let Them Shine experience
  2.  Agree to Straumann Group North America using the video footage, photos, submission photos/xray images, etc., for a separate case documentation or video to be used to educate other patients in North America about implant treatment in marketing efforts such as Let Them Shine and Straumann Group publications including but not limited to the Straumann Group North America websites: (Straumann.com, letthemshineusa.org, letthemshinecanada.org, letthemshineworldwide.org, teethtoday.com, straumann.us, straumann.ca, neodent.us, neodent.ca, etc.) and brochures.
  3. Sign a release that includes the above agreements

 

Clinician Criteria:

  • Clinician is willing to donate their time and services for the benefit of the patient.
  • Clinician will use only donated Straumann Group (Straumann or Neodent) implants and prosthetics for this case.
  • Clinician must be experienced and capable of completing the proposed procedure for the patient.
  • Clinician agrees to follow Straumann products' Instructions for Use (ifu.neodent.com.br/en or ifu.straumann.com).
  • Clinician will provide the patient with adequate instructions for care after the procedure and all necessary follow-up maintenance as deemed appropriate in     the clinician’s professional opinion.
  • Clinician must work with Straumann Group to find a surgery date that works for video production and discuss with Straumann Group any changes in that date well in advance of the surgery.
  • Clinicians without an internal lab or a lab willing to provide the services free of charge will be required to use Straumann Group Centralized Production Center to fabricate the final prosthesis for the case.

Because the clinician is a vital part of the story of transformation for patients as described above, clinicians for accepted patients must be willing to help facilitate getting both a before and after photo of the patient’s smile and the patient’s written testimonial or letter to Straumann Group for use in promoting Let Them Shine and to create a separate case documentation or story to be used to highlight the benefits of implant procedures for other patients:

In addition, if the patient is selected for the documentary-style video, the clinician for the accepted patient must be:
 

  1. Unable to get this procedure without the assistance of Let Them Shine 
  2. Be photographed and participate in video interviews and video shoots at their practice (which may include staff interviews) before and after surgery and following final restoration to chronicle the patient’s oral health journey, the reason the patient was submitted as a case, and the Let Them Shine experience.
  3. Obtaining the patient’s consent to participate in the documentary-style video and to allow Straumann Group North America to use the video footage, photos, submission photos/xray images, etc., for a separate case documentation or video to be used to educate other patients in North America about implant treatment in marketing efforts such as Let Them Shine and Straumann Group publications including but not limited to the Straumann Group North America websites (Let Them Shine (straumann.com), teethtoday.com, straumann.us, straumann.ca, neodent.us, neodent.ca, etc.) and brochures.
  4. Sign a release that includes the above agreements

The Straumann Group will donate: implants, restorative components, lab fees (when applicable), the cost of temporary and final restoration.

This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid email address.
13. Will you be using Straumann Group Smile in a Box? *This question is required.
14. Will Straumann Group Digital Solutions products be leveraged for this case? *This question is required.
18. Please check the box to certify *This question is required.
19. Would you like a tax write-off for your donated services?  *This question is required.
22. Patient Health Risks (check all that apply) *This question is required.
23. Does the patient consent to sharing before and after photos showing their smile (without other identifying characteristics) as well as a written testimonial or letter about their experience with the surgical procedure and Let Them Shine, and highlight the impact both had on their life, understanding that the photos will be used to promote Let Them Shine and the benefits of implant procedures for other patients? *This question is required.
24. If chosen for the documentary-style video, does the patient consent to being photographed and participating in video interviews and video shoots at their home, work, etc., before and after surgery and following final restoration to chronicle their oral health journey and the Let Them Shine experience, understanding that the photos will be used to promote Let Them Shine and the benefits of implant procedures for other patients? *This question is required.
25.

To inspire other patients to explore implant therapy, does the patient consent to: Straumann Group North America using their video, photos, submission photos/xray images, etc., for marketing efforts including, but not limited to: patient wall at Straumann Group North America headquarters, internal town hall meetings, company annual reports, and website content on Let Them Shine (straumann.com), letthemshineusa.org, letthemshineca.org, letthemshineworldwide.org, teethtoday.com, straumann.us, straumann.ca, neodent.us, neodent.ca, etc.?

*This question is required.
26. Does the clinician agree to sharing their experience and facilitating before and after photographs and a written testimonial from the patient to be used to promote Let Them Shine and implant procedures to other patients, and a written testimonial or letter to highlight the patient’s experience with the surgical procedure, Let Them Shine, and the impact the procedure had on their life? *This question is required.
27. If the patient is chosen to participate in a documentary-style videos, does the clinician consent to: being photographed and participating in video interviews and video shoots at their practice (which may include staff interviews) before and after surgery and following final restoration to chronicle the patient’s oral health journey, the reason the patient was submitted as a case, and the Let Them Shine experience, understanding that the photos will be used to promote Let Them Shine and the benefits of implant procedures for other patients? *This question is required.
28. To inspire other patients to explore implant therapy, does the clinician consent to: Straumann Group North America using their video, photos, etc., for marketing efforts including, but not limited to: patient wall at Straumann Group North America headquarters, internal town hall meetings, company annual reports, and website content on Let Them Shine (straumann.com), letthemshineusa.org, letthemshineca.org, letthemshineworldwide.org, teethtoday.com, straumann.us, straumann.ca, neodent.us, neodent.ca, etc.? Please note that the publicity from these videos may generate requests from other patients in need of free services. *This question is required.
30.

If the patient or clinician is unable to participate in a video, or if the case is not selected for a before/after video shoot, is the patient willing to provide a written testimonial about their oral health journey and the transformation enabled by Let Them Shine that can be used by Straumann Group and its brands for marketing purposes (listed above)?

Requested Donation Amount
34. Please upload the itemized estimate from any vendor  that will have fees associated with this case that are not being donated by Straumann Group Centralized Production Center or any other donors (Clinician and/or Clinician preferred lab).

NOTE: This amount is highly considered within the review process and should be as accurate as possible. A buffer of 10% will be provided for any instances where the final costs are higher than the amount requested in this section. Any amounts exceeding the 10% are subject to approval by the Let Them Shine Committee. *This question is required.
36. When could the surgery be scheduled?  *This question is required.
38. How did you hear about Let Them Shine?  *This question is required.

CONDITIONS FOR CASE SUBMISSION
If chosen to receive Let Them Shine Funds, Practitioner agrees to adhere to the case submission conditions listed herein.  

Case is valid only if this case submission form is completed and duly signed by the Practitioner and sent in together with the Case Documentation consisting of digital images including legends, a brief patient history as described hereafter in the Case Documentation Requirements.

Each Practitioner individually represents and warrants that only Straumann Group products will be used. Only treatment plans where Straumann products will be used in accordance with the product's Instructions for Use (ifu.neodent.com.br/en or ifu.straumann.com) will be considered for selection by Let Them Shine.

Let Them Shine is affiliated with the Straumann Group Centralized Production Center located in Arlington, TX. Submitting clinicians without an internal lab or a lab willing to provide the services free of charge will be required to use Straumann Group Manufacturing to fabricate the final prosthesis for the case. Restorative materials available through Straumann’s manufacturing facility include milled monolithic crowns and bridges, CAD/CAM abutments, Titanium bars, and full arch zirconia prostheses. This will allow Let them Shine to manage spending efficiently and support many more patients in need.

The Practitioner(s) individually represent and warrant to be the exclusive author(s) and exclusive owner(s) of all rights related to the Case Documentation submitted and that no manipulation other than cropping, rotating and/or adjustments of contrast and brightness have been performed on the digital images presented with the Case Documentation, and that all registered Practitioners were actively involved in the treatment. Each Practitioner individually represents and warrants that all information given in connection with the Case Documentation is true and valid.

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. 

All Case Documentation will be subject to Straumann USA, LLC Legal and Regulatory review and will only be accepted after final approval.

CASE DOCUMENTATION CHECKLIST
The Case Documentation may either be provided on a CD, USB Flash Drive or via email. Photographs are to be converted into a digital format. Digital images must be submitted in TIF or JPEG format and should have print quality (min. 300 dpi resolution).

An abstract of patient initial situation; chief complaint, diagnosis with explanation for why the StraumannGroup restorative solution was/were chosen, treatment protocol and results at furthest follow up time point in a common digital text format must be included with the Case Documentation. The maximum length of such abstract should not exceed 1500 words. The text must be in English.

Abstract should include the following information:

  • Description of the patient: age, sex, (non)smoker, any systematic diseases, patient history. 
  • Description of the initial situation
  • Description of planning and performance of the surgical operation and dental lab procedure
  • Precise details of the Straumann products employed (e.g. Straumann® BLT Implants, Variobase®, n!ce® etc.)
  • Clinical result immediately after the treatment 
  • Clinical results after placement of the final prosthesis
  • Treatment outcome from the patients’ point of view (potentially participate in a testimonial video with the patient)
  • Testimonial from treating clinicians about Straumann® restorative solutions as a practice differentiator

The number of digital images submitted must not be fewer than 2 and not more than 18. Digital images should include at least one pre-operative image and one post-operative displaying the entire treatment area. All digital images must be numbered consecutively and indicate length of time since treatment. 

MISCELLANEOUS
Case documentation submitted to Let Them Shine by Practitioner(s) may be featured on Straumann USA, Straumann Canada, Neodent USA or Neodent Canada, Let Them Shine or Straumann Group promotional materials to include education pieces, marketing, website, newsletters, social media, eNews, emails, print, online or other media, etc., at Let Them Shine's discretion.

The Case Documentations submitted will not be returned to the Practitioners.

This Case Submission Form is governed by US law. The exclusive place of jurisdiction is the ordinary courts of Delaware.

Clinician represents and warrants that the clinician will provide the patient with adequate instructions for care after the procedure and provide all necessary follow up maintenance as deemed appropriate in the clinician’s professional opinion.

ASSIGNMENT OF RIGHTS
The Practitioner(s) grant and herewith irrevocably assign to Let Them Shine and its affiliates 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. 

The Practitioner(s) herewith entitle Let Them Shine and its affiliates to edit the Case Documentation with respect to format and language. Any changes will be sent to Practitioners prior to publication for permission. Prior to any publication of a Case Documentation according to rights granted above, whether edited or not, Let Them Shine shall inform Practitioner 1 as named on page 1 of this Case Submission Form. With any publication of the Case Documentation, either edited or not, the name of each Practitioner as is stated on the case submission form will be published. Each Practitioner herewith warrants that their name, position and title are accurate. 

Let Them Shine and Straumann Group North America reserve the right to use the Case Documentations and any photos/video shot before/after surgery and following final restoration in all Let Them Shine and Straumann Group publications including but not limited to the Straumann Group North America websites (Let Them Shine (straumann.com), teethtoday.com, straumann.us, straumann.ca, neodent.us, neodent.ca, etc.)

By submitting this Case Submission Form, Practitioner accepts the terms and conditions of this Case Submission Form as binding terms and conditions for participation and undertakes to adhere to the terms and conditions in this Case Submission Form.

By completing this form, you agree to receive email communications from Straumann Group North America.

Straumann Group North America 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.