OMS Guide Order Form: Wafer/Splint Guide - SimPlant Academy

OMS Guide Order Form: Wafer/Splint Guide
The final shipment date of your order, and as such the date of receipt of the ordered parts, will depend on the date of
receipt of this form and all data at Materialise Dental.
Price (depending on the number of wafers/splints ordered for the same case):
1 wafer (final OR intermediate) €395 (+VAT)
2 wafers (final AND intermediate) €495 (+VAT)
Other Please request quotation
MATERIALISE DENTAL WILL CHECK THE FEASABILITY OF EACH REQUEST. IF IT IS NOT
REALISABLE, THE CUSTOMER WILL BE INFORMED AS SOON AS POSSIBLE.
Normal delivery time: An OMS guide will be built and finished within seven working days after receiving this form,
the planning data, the plaster models, and a specifications form for the design of the guide. The means of
transportation of the plaster models and the guide(s) will determine the total delivery time.
Order placement information
Delivery due date:
Date of intervention:
Shipping address:
Invoice Address:
VAT N o (if applicable):
Contact person:
Telephone :
E-mail address:
Patient Data
Project Name:
Data Submitted via:
Special Remarks or Warnings:
Wafer/Splint order specifications
Intermediate wafer/splint
Final wafer/splint
Other:
Plaster casts
are shipped together with this form
are already at Materialise Dental
will not be shipped (included in SimPlant file)
maxilla first mandible first

Wafer/Splint design specifications
Please specify how the guides should be designed. In case a different design is needed for different
guides, please specify this in the remarks below.
Depth of the impressions
o Shallow (approx. 1mm)
o Medium (up to bracket level)
o Deep (including bracket level)
Width of the buccal contour
o Thin (approx. 1mm outside the tooth impressions)
o Wide (approx. 3 mm outside the tooth impressions)
Remarks about the design:
I, ………………………., hereby request the manufacturing of an OMS Guide by Materialise Dental,
according to my pre-operative surgical plan. I declare having the qualifications required by law to perform
the planned intervention and take full medical responsibility for the design and the application of this
guide. I further declare agreement to the limitation of liability listed below.
Signature:

Limitation of liability
Materialise Dental N.V. is liable as a supplier of products. Since the circumstances in which these products are
ordered and used are under control of the buyer, the latter recognizes his responsibility for these circumstances. On
these grounds the remedies of the buyer are limited as follows:
The liability of Materialise Dental N.V. for real and proven damages will, regardless of the gravity of the failure, except
in case of fraud, be limited to the price of the product directly related to the reason of the claim.
Under no circumstances an indemnity can be grounded on indirect damages such as, but not limited to, loss of
revenue, increase of expenses, disturbance of planning, loss of customers or goodwill, loss of benefits or expected
savings or any other financial or commercial losses which are not a direct and immediate consequence of a
shortcoming of Materialise Dental N.V. in its obligations.
The Client hereby represents and warrants that he has requested and received the duly informed consent of the
patient to use its private and medical information during the ordering and delivery process of the Surgical Guide, in
compliance with all applicable laws, including any applicable privacy regulations.
Buyer agrees to control the conformity of any delivered product with his order, before using it. Should buyer
omit to perform such control or decide to nevertheless use a non conformable product, he frees Materialise
Dental N.V. from any liability for the consequences of the use of such product.
Materialise Dental E-mail: surgiguide@materialise.be
Technologielaan 15 Tel.: + 32 16 39 66 20
3000 Leuven Fax: + 32 16 39 66 22
Belgium
Sending out this form with a signature will be considered an order. Prices and product specifications may
change at any time without prior notice. Shipping costs, import taxes and customs charges are on the
account of the buyer.