LAB INFORMATION

Prescribing Clinician Zip Code:
Patient ID

Bill To:
Account Name
Account No
Contact
Address

City State Zip
Phone
Email

Ship To: Same as billing address?
Name
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 – BellaTek® 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

Global Headquarters
4555 Riverside Drive
Palm Beach Gardens, FL 33410
1-800-342-5454
Outside the U.S.: +1-561-776-6700
Fax: +1-561-776-1272
www.biomet3i.com
EC
REP

BIOMET 3i
Europe, Middle East & Africa
WTC Almeda Park, Ed. 1, Planta 1 a
Pl. de la Pau, s/n
08940, Cornellá de Llobregat
(Barcelona) Spain
Phone: +34-93-470-55-00
Fax: +34-93-371-78-49

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 Website.
Encode® Impression System Work Order Form
FINAL ABUTMENT HEIGHT (For reference only)
Default 2.5mm from opposing or adjacent dentition,
whichever marginal ridge is lower, unless otherwise specified.
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TISSUE DISPLACEMENT (For reference only)
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
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MARGIN STYLE (For reference only)
Apply same settings for all abutments
SPECIAL INSTRUCTIONS
Design Review

Lab Screws (5-Pack)

Duplicate Abutment

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.

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Make Parallel*
*Specify tooth number for parallel abutments in Other Instructions
Tooth #
Change
Numbering
Abutment
Material
Margin Style
Margin Depth
Tissue Displacement
Final Abutment
Height
Clearance
Robocast
Only  
Buccal
Lingual
Distal
Mesial
      
      
      
      
      
      
      
      

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