Prescribing Clinician Zip Code:
City State Zip
Ship To: Same as billing address?
City State Zip
Certification (by submitting this Work Order Form you certify the following):
• The stated information is correct, the submitted materials are accurate and do not contain metal.
• All items that have contacted the oral environment have been decontaminated.
• For the Laboratory – I, the laboratory, certify that I have reviewed the applicable instructions (ART1080, ART1120 – BellaTekÂ® Encode Impression System Laboratory Recommendations) for this product.
• For the Clinician – I, the clinician, certify that I have reviewed the applicable instructions (ART1079, ART1161, ART1156, ART1147 – BellaTek Encode Impression System Clinician Procedures) for this product and verify that the soft-tissue has matured and healed completely.
This form authorizes the following:
• Fabrication of patient specific abutments
• Placement of analogs
• Modification of working models not consistent with applicable guidelines
4555 Riverside Drive
Palm Beach Gardens, FL 33410
Outside the U.S.: +1-561-776-6700
Europe, Middle East & Africa
WTC Almeda Park, Ed. 1, Planta 1 a
Pl. de la Pau, s/n
08940, Cornellá de Llobregat
BellaTek, BellaTek design, Encode and Gold-Tite are registered trademarks of BIOMET 3i LLC. Providing Solutions - One Patient At A Time is a trademark of BIOMET 3i LLC. ©2013 BIOMET 3i LLC.
All trademarks herein are the property of BIOMET 3i
LLC unless otherwise indicated. This material is intended for clinicians only and is NOT intended for patient distribution.
This material is not to be redistributed, duplicated, or disclosed without the express written consent of BIOMET 3i
. For additional product information, including indications, contraindications,warnings, precautions, and potential adverse effects, see the product package insert and the BIOMET 3i
Default 2.5mm from opposing or adjacent dentition,
whichever marginal ridge is lower, unless otherwise specified.
Minimal Tissue Displacement (Default)
Moderate Tissue Displacement
Anatomical Tissue Displacement
Healing Abutment - black circle
Margin - outer grey line
Option 3 may require tissue adjustment and relief for placement
Apply same settings for all abutments
Case Information: Abutments will be designed to match the emergence profile of the BellaTek® Encode® Healing Abutment unless otherwise noted. Abutments will be designed to match default settings unless otherwise specified. Please note any other special instructions below.
*Specify tooth number for parallel abutments in Other Instructions