Clinician Information

NCENTER

WORK ORDER

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CASE ID ---------------------------------------------------------------(For MCENTER Use Only)

WORK ORDER -------------------------------------(For MCENTER Use Only)

Doctor Name---------------------------------------------------------------------------------------

Contact Name _____________________________________________________________________________________ _ (if other than Doctor)

Customer*-----------------------------------------------------------------------------------------

Street Address-----------------------------------------------------------------------------------­

City, State, and Zip Code

Telephone -------------------------------------------------------------------------------------------

Email (required} __________________________________________________________________________________ _

State License Number _______________________________________________________________________ _

Patient Information

Patient Name/Case ID ----------------------------------------------------------------------­

Date of Birth ----------------------------------------------------------------------------------------­

Gender (circle one) M / F

1

2

Enclosed Items

D Maxillary Impression

D Maxillary Model

D Maxillary Wax Up

D Bite Registration

D Soft T issue Moulage

D Mandibular Impression

D Mandibular Model

D Mandibular Wax Up

D Articulator

If sending Impressions: D Impression Copings included

D Analogs included

Service

Milling Center Services

Restoration Type

*PMMA Temporary

*Custom Final Zirconia Abutment

Custom Titanium Abutment

Custom Titanium Abutment from STL

Tooth #(s) Shade *"Type of Final

*VITA TM Classical Shade Guide VITA TM is a registered trademark of The VITA Company

**e.max®, PFM, Zirconia Crown This information is needed to determine the correct

finishing of abutment margins

NOTES

Questions? Contact our Digital Dentistry Specialists I 18-00 Fair Lawn Ave. Fair Lawn, NJ 07410 I Phone: 201.710.6236 I Fax: 201.797.9145 I Email: mcenterusa@misimplants.com

*Custom Final Zirconia Abutment from STL

4Tooth and Implant Properties

Example of bridge #18-21

(Please indicate if restorations are single units or bridges)

QXxO uu u A � � A A A A � � U u uu

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Tooth Number Implant Series Diameter Notes

NOTES

Questions? Contact our Digital Dentistry Specialists I 18-00 Fair Lawn Ave. Fair Lawn, NJ 07410 I Phone: 201.710.6236 I Fax: 201.797.9145 I Email: mcenterusa@misimplants.com

3

Do not proceed without Customer Approval. If box is

unchecked, case will proceed without customer approval.

Concave Convex

Emergence Profile

Default Parameters

Minimum 2.5 mm from opposing or adjacent dentition, whichever

marginal ridge is lower, unless otherwise specified.

Emergence Profile: Buccal - Minimum 1-1.5 mm subgingival

Mesial-Distal - Minimum 1 mm subgingival

Lingual - Minimum 0-+ 1 supragingival

Abutment Parameters

(Select Default or Custom)

Minimum diameter for Zirconia abutment on titanium base level

is 4.7 mm. Minimum height for Zirconia abutment on titanium

base level is 5 mm.

Custom Parameters

mm from opposing or adjacent dentition, whichever

marginal ridge is lower

Emergence Profile: Buccal -

Mesial-Distal -

Lingual -

mm subgingival

mm subgingival

mm supragingival

Minimum diameter for Zirconia abutment on titanium base level is

4.7 mm. Minimum height for Zirconia abutment on titanium base

level is 5 mm.

Straight

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Terms & Conditions

The services and products of CAD/CAM 360, a division of MCENTER USA, LLC, (MCENTER) are subject to the following terms and conditions. Any shipment of products shall be deemed to be on these terms and conditions. Any and all terms and conditions submitted by purchaser are hereby rejected. These terms cannot be varied by any oral promises, statements or representations. Limited Warranty MCENTER USA LLC exercises great care and effort in maintaining the superior quality of its products. We warrant that the products produced will be free from defects in materials and workmanship. The dentist has the right to inspect the case prior to acceptance provided that notice of non-acceptance or non-conformance of the case shall be communicated to the MCENTER within a period of 14 days from receipt of the case. If the product has defects in material or workmanship, or if the product does not meet the MCENTER quality standards, or if the product does not match the MCENTER order form completed and signed by the clinician prior to the design of the product in question, MCENTER will remake the product, at no additional charge. The warranty for the products is granted for the following periods: Titanium restorations- seven (7) years from day of milling. Zirconia products - five (5) years from day of milling Duplicate Remake Policy There is a one-time 50% discount on custom abutments when original impressions/files are used. Additional remakes will be considered to be new orders. Claim Procedure To receive benefits from these terms and conditions, the following criteria must be met when submitting a claim: 1. Unaltered and decontaminated product must be returned along with the MCENTER Warranty Claim Form which can be obtained by contacting the MCENTER. 2. The case must have been inserted by a licensed, practicing dentist. Exclusions This warranty becomes void if the abutment has been modified, grinded, or otherwise retouched or altered. Cash refunds for custom-made abutments are excluded from this warranty. If MCENTER requests a new impression, but is instructed by Client to proceed without the new impression, the warranty shall be null and void and any further remakes will be completed at full cost to client. Limitation of Liability Except for the warranty specified in these Terms and Conditions, neither MCENTER, not its affiliates, nor any representatives or other third parties which manufacture or distribute the products can make any representation, warranty, covenant or other undertaking, expressed or implied, written or oral, with respect to the products, including (without limitations) any implied warranties of a merchantability, durability or fitness for a particular use of purpose. This document incorporates all oral and written representations between the parties and constitutes the entire agreement and understanding of the parties with respect to the subject matter hereof and supersedes any and all other agreements either oral or written between the parties with respect to such subject matter. No amendment or modification may be made to this document unless in writing and duly executed by an authorized representative of MCENTER. In addition, and to the maximum extent permitted under the applicable law, MCENTER disclaims (on behalf of itself and any of its representatives or other third party which manufacture or distribute the Products) any and all liability with respect to lost earnings, incomes or profits, special, indirect, incidental or consequential damages resulting or arising from the design, composition, condition or any nature and from any cause whether based on contract, tors (including negligence) or other legal theory, even if MCENTER has been advised of the possibility of such damages. Modification or withdrawal of the Warranty MC ENTER reserves the right to modify or withdraw these terms and conditions at any time without notice. Any such modification or withdrawal will not affect products already installed in a patient and fully paid by the clinician.

By signing, I acknowledge that I understand the above Terms and Conditions.

Name (Please print)--------------------------------------------........................................... Title _____________________ _

Signature (Required)-----------------------------------------.........................................--- Date----------------------

NCENTERUSA

Questions? Contact our Digital Dentistry Specialists I 18-00 Fair Lawn Ave. Fair Lawn, NJ 07410 I Phone: 201.710.6236 I Fax: 201.797.9145 I Email: mcenterusa@misimplants.com