Encode® Impression System Work Order Form
COMPLETE ENTIRE FORM LEGIBLY or use the BellaTek™ ™ Encode® ® Impression System PDF Order Form available at www.biomet3i.com
  Account Information   Robocast Only   Screw Ordering  
 
Prescribing Clinician Zip Code:
Patient ID
Bill to:
Account Name
Account
Contact
Address
City State Zip
Phone
Email
Country
If Different From Above:
Ship to:
Name
Address
City State Zip
Design Guidelines And Defaults
Subgingival Margin Depth Default
Buccal/Facial 1mm Distal 1mm
Lingual           1mm Mesial 1mm
Interocclusal Clearance Default
Metal
2 mm
PFM 2 mm
All Ceramic 2 mm
     
Special Instructions
     
     
Margin Style (For Reference Only)
 
Certain® Internal Connection Abutment Screws Quantity
Gold-Tite® Hexed (IUNIHG)
Titanium Hexed (IUNIHT)
Laboratory Hexed Try-in Screw - 5 pack (IUNITS)
   
External Hex Connection Abutment Screws Quantity
Gold-Tite® Square (UNISG)
Gold-Tite® Hexed (UNIHG)
Titanium Hexed (UNIHT)
Laboratory Square Try-in Screw - 5 pack (UNITS)
3.4mm Square Try-in Screw - 5 pack (MUNITS)
   
Case Information: Abutments will be designed to match the emergence profile of the BellaTek™ Encode® Healing Abutment unless otherwise noted. If there is not enough space for the margin depth that is requested, the margins will be made as short as possible. Please specify whether the abutment should push soft tissue, where and by how much. Defaults will be used if no selections are made (defaults noted by superscript)
 
 
Abutment Information Design Information
Tooth
Position 		Abutment Material Duplicate
Abutment 		Analog Placement/
Robocast 		Margin Style
  Ti † TiN Zirconia *   Yes † No Shoulder † Chamfer Feather Edge
*Zirconia is available for Certain® Internal Connection Implants, anterior 3.4mm, 4.1mm and 5.0mm up to 30°, premolar 4.1mm up to 20° and 5.0mm up to 30°, molar 5.0mm up to 20° only. 		 
Certification (by submitting this work order you certify the following)
  • The stated information is correct and that the submitted materials are accurate and do not contain metal.
  • All items that have contacted the oral environment have been disinfected.
  • This form authorizes BIOMET 3i to fabricate the patient specific abutment(s) and place analogs using and consistent with the information provided on this Work Order Form.
  • I have reviewed the applicable instructions (ART1079, ART1080, ART1087) for this product.
 
Certain® , Encode® and Gold-Tite® are registered trademarks and BellTek and Providing Solutions – One Patient At A Time and design are trademarks of BIOMET 3i LLC. BIOMET is a registered trademark and BIOMET 3i and design are trademarks of BIOMET, Inc. Stratos is a trademark of Ivoclar Vivadent. ©2011 BIOMET 3i LLC. All rights reserved.
REV J 01/11
 
BIOMET 3i
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

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


 
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