3M Incognito™ Lite Appliance System Template

Booking
(Mo - Fr 8 am – 5 pm)
Tel.: +49 (0)5472 – 94 91 – 0
Fax: +49 (0)5472 – 94 91 – 276
Please submit impressions to:
TOP-Service für Lingualtechnik GmbH · A 3M Company
Schledehauser Straße 81 · 49152 Bad Essen · Germany
E-Mail: [email protected] · www.incognito.net
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1
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Lab Order Form
PLEASE FILL OUT IN CAPITAL LETTERS
Patient (Surname)
Patient (First Name)
Date of birth
Patient Code
Gender 1
Phone
Orthodontist
Fax
Address / Postcode
Email
on _________________________________________________________________________ at _____________________________ h
Date and time of bonding
Address / Country
female
male
_____________________________________________________________________________________
In your country the transfer of personal health data to a laboratory may
be subject to legal restrictions, e.g. written patient consent.
VAT-ID (See notice on reverse side)
To be filled out by TOP-Service:
Please inform us immediately if the shipping address
is different to the invoice address.
Please tick if orthodontist name should be stated
additionally on the invoice
Please fully complete the treatment plan (in the red box)
2
MAX
MDB
Appliance recommended by TOP-Service
SetupMAX
MDB
Remarks
Arch to be bonded with Incognito System
Set of archwires MAX
Wires required
(please tick)
Manual Setup3
Digital Setup3
straight indiv.
lat. sec. lat. sec.
12 Ø
Incognito™ Clear Precision Tray
Thermoplastic Tray
2-Phase Silicone Tray
Silicone Tray
(Non-transparent)
14 Ø N
(Transparent, Vacuum molded)
SE NiTi
(Only with DSL Setup)
(Transparent)
Finishing class
Stripping MAX
Right / Left
E
N
EN
16 x 22
yes, if necessary
Canine _____ / ______
E
16 x 22
18 x 25
essential ______ mm
Molar _____ / ______
16 Ø
17 x 25
16 x 22 ET*
Steel
no stripping
16 x 24
16 x 24 ET**
EN
18 x 25
Bracket series
MAX
Extras
3BP
TH
TL
TI
Ribbonwise VH
For an ex-case please indicate space closure or not.
Please fill in: B = bracket; T = tube; Ex = to be extracted; X = missing;
casted ring = circle tooth; occlusal pad surface = shade in
Beta III Titanium
18 x 25 (red.)
17,5 x 17,5
17 x 25
18,2 x 18,2
=
=
=
=
=
Bite plane on 3´s
Tube with hook
Possible
Tube extra long
Combinations
Tube with easy insertion
MDB anteriors “self ligating“ 3-3
Bracket series
MDB
Stripping MDB
ET* =
ET** =
red. =
E =
N =
=
18,2 x 25
Extra torque of 15°on 11/21
Extra torque of 13°on 3-3
laterally reduced
recommended wire for Ex-cases
recommended wire for Non-Ex-cases
not recommended
Set of archwires MDB
Extras
3-3SL
TH
TL
Ribbonwise VH
TI
Wires required
(please tick)
14 Ø
SE NiTi
yes, if necessary
16 x 22
18 x 25
Class II Correction Devices
Steel
Herbst® Appliance
EN
16 x 24
E
N
18 x 25
18 x 25 (red.)
2 Lower Arch Attachments incl.
Forsus™ Push Rods (L-Pin) 1-Patient Kit 885-126
Please Indicate
L = Labial Lower Arch Attachment on the template
1
2
3
I accept the General Terms of Sale covered overleaf.
E
N
16 x 22
Herbst® Appliance
2 Lower Arch Attachments incl.
Forsus™ EZ2 1-Patient Kit 885-143
Stamp, date and signature
E
N
16 Ø
17 x 25
no stripping
2 Lower Arch Attachments straight indiv.
lat. sec. lat. sec.
12 Ø
Remarks
essential ______ mm
Forsus™ Fatigue Resistance Device
E N
5 wires per arch are included in the price
3BP
TH
TL
TI
3-3SL
Beta III Titanium
___
Orthodontic Practice
17,5 x 17,5
17 x 25
18,2 x 18,2
E N
18,2 x 25
In addition date of birth and gender are to be given by choice for internal use.
We wish to make it very clear that this is only a recommendation from TOP-Service. The decision to treat
with this system, and to realise your treatment plan, is entirely your decision as treating orthodontist.
See notice on reverse side.
Please recycle. Printed in Germany.
© 2014 3M. All rights reserved.
FB-7.5.1-60a-Laborauftrag Incognito (EN)_m_26.05.2014
General Terms of Sale
1. General: The sale of our products and other services is subject exclusively to the following
General Terms of Sale. Divergent purchasing terms of the purchaser’s are herewith expressly
rejected. These terms of sale are deemed to have been accepted without reservation by the
purchaser, even if he has previously raised objections to them, at the latest when he takes delivery
of our products or accepts our services. Any other agreements that deviate from these terms of sale
are only valid with our express prior consent in writing for every individual contract. These terms of
sale apply only in relation to enterprises as defined in § 14 of the Civil Code (BGB).
Our offers are subject to prior sale.
2. Prices: Unless otherwise agreed, the prices are calculated on the basis of the current price on the
day of delivery or performance plus the statutory rate of value-added tax. Unless otherwise agreed,
the purchaser shall pay the delivery costs.
3. Dispatch; Passing of risks: The goods will always be shipped dispatched at the purchaser’s risk,
except otherwise agreed. The risk passes to the purchaser as soon as the goods are handed over to
the forwarding agent, at the latest when they leave our factory or warehouse.
4. Deliveries: The delivery times quoted by us represent the probable dates of delivery which we
shall endeavour to observe. Agreed delivery dates are only binding if all details of the order are
clarified in advance and the purchaser duly fulfils all his obligations. If a delivery date that has
been expressly agreed in writing is not observed due to our fault, the purchaser will grant us an
appropriate extension period in writing. If we still fail to deliver during this extension period, the
purchaser is entitled to withdraw from the sales agreement. Any compensation claims for delay
are subject to the provisions of Section 10. Circumstances or events beyond our control that make
deliveries delayed, impossible or unreasonably difficult, such as war, intervention by sovereign
powers, natural disasters, accidents, traffic breakdowns, operational stoppages, shortages of raw
materials and power, strikes and lock-outs, even if they occur at our suppliers, release us from our
delivery obligations for the duration of the disruption plus an appropriate set-up time. If it appears
that the disruption will not come to an end within a reasonable period of time, we are entitled to
withdraw from the contract either in full or in part without any obligation to deliver at a later date.
If the purchaser defaults on acceptance or culpably fails to comply with other obligations, we are
entitled to demand damages including the payment of possible additional expenses. We reserve the
right to bring other claims.
5. Right to return: Individually manufactured or made-to-order products are excluded from return.
All other TOP-Service products, without defects in materials and workmanship, may be returned at
the expense of purchaser within 14 days after dispatch. We will only reimburse price for a returned
product, if the product is unused, unopened in original, undamaged packaging and in a resaleable
condition. The returned product has to be accompanied by a copy of the original invoice and a letter
describing the reason for the return.
6. Payments: Our invoices are payable without deduction within 30 days of the date of the invoice.
Payments shall be considered to have been made on time once the amount has been received by us
and is at our unrestricted disposal. If the payment period is overdrawn or the full amount is not paid
in time, the purchaser shall be considered to be in default, even if no reminder is sent, at the latest
30 days after receipt of the invoice. As soon as the purchaser is in default, we are entitled, without
prejudice to any other claims, to charge interest on arrears at a rate of 8 % over the current base
rate in accordance with §087 of the Civil Code (BGB). The purchaser can only offset undisputed or
legally proven claims and can only exercise a right of retention in respect of claims arising from
the same contract.
7. Property rights: The goods supplied remain our property until the purchase price and all other
existing or future claims from the transaction have been paid in full (goods under reserve). The
purchaser is entitled to sell the goods under reserve in the course of his normal business as long as
he meets his contractual obligations to us. He is not allowed to pledge the goods or use them as
security; he must notify us without delay of any infringement of our property rights by third parties.
If the purchaser does not fulfil his contractual obligations to us, we are moreover entitled to demand
the return of the goods under reserve; in this respect the purchaser has no right of possession.
8. Information; Advice: All verbal or written information about the suitability of our products for
certain applications is given in good faith. This does not exempt the purchaser from the obligation
to verify for himself the suitability of the product for his intended purpose.
9. Warranty: We warrant the exact suitability of the individual brackets only for the geometry of
the teeth represented in the impressions, provided, however, that the doctor providing medical
treatment examines the correctness of the appliance in its entirety and all of its components, which
have been manufactured by us as custom-made product according to his instructions and at the
TOP-Service für Lingualtechnik GmbH · A 3M Company
Schledehauser Straße 81 · 49152 Bad Essen · Germany
Tel.: +49 (0)5472 – 94 91 - 0 · Fax: +49 (0)5472 – 94 91 - 19
E-Mail: [email protected] · www.incognito.net
commencement of the treatment assumes full responsibility for the whole continuance of the treatment. Before making any warranty claims, the purchaser must first have duly complied with the
obligations relating to product examination and the proper complaints procedures contained in
§ 377 of the Commercial Code (HGB). Warranty claims by the purchaser are not permitted if the
defect was caused by the improper transport, storage, handling or processing of the goods supplied.
Moreover, warranty claims are not permitted for natural wear and tear. If the purchased goods are
legitimately defective, the purchaser is entitled at our discretion either to have the defect remedied or to receive a defect-free replacement. If this does not succeed in solving the problem, the
purchaser is entitled at his discretion to demand a reduction in the purchase price or to be released
from the contract. We accept liability for any fraudulent concealment of a defect and for the absence
of warranted qualities. Otherwise claims for compensation in respect of defects are subject to the
provisions of Section 10. The period of limitation for warranty claims is 12 months from the delivery
of the goods. This does not apply to the period of limitation in the event of recourse under §§ 478,
479 of the Civil Code (BGB).
10. Liability: We accept liability for intent and gross negligence. We are also liable for any culpable
breach of major contractual obligations; however, if a breach of major contractual obligations is
due to negligence, our liability is limited to the foreseeable damage associated with this type of
contract. This does not affect our liability for culpable fatal or bodily injury or damage to health; this
also applies to liability under the Product Liability Act (“Produkthaftungsgesetz“) and the Medical
Preparations Act (“Arzneimittelgesetz“). Other claims for compensation are excluded.
11. Place of performance: The place of performance for our deliveries is the respective place of
dispatch. The place of performance for the purchaser’s payment obligations is Bad Essen.
12. Applicable law; Place of jurisdiction: All legal relations between the purchaser and us shall be
subject exclusively to the relevant laws of the Federal Republic of Germany governing legal relations
between domestic parties. Any legal disputes shall come under the jurisdiction of the courts at our
place of business. However, we can also take legal action against the purchaser in the courts of the
purchaser’s place of general jurisdiction.
Issued: 08 / 2012
Notice
VAT-ID: The following remark is only applicable if you are resident in an EU member state, other than
Germany: Please include the VAT identification number you obtained from the tax authorities of your
home country, if available. The entry of your valid VAT identification number is a key prerequisite
to receive an invoice from TOP-Service für Lingualtechnik GmbH without VAT.
Setup: We always need one silicone impression for each arch that is to be bonded - for opposing
arches a plaster model is sufficient. All impressions and models must be completely disinfected
prior to despatch to TOP-Service. For details regarding impression taking or other detailed information please look at our website www.incognito.net or contact us directly. If you only want us to
position one arch, please nevertheless always indicate if you plan any treatment for the opposing
arch - even if it is labial. We would bring to your attention that all items despatched by us are not
classified as sterile.
Data Privacy: Customer is responsible that providing of all order data meets all applicable laws
of customer country (i.e. pseudonymisation or informed patient consent). Since personal health
data in the Order Form is considered sensitive health data in the EU, you should use a pseudonym
(number) instead of patient name. TOP-Service and it‘s contracted partners process the data from
the Lab Order Form solely to fulfil the contracted services in full compliance with applicable EU
and German Data Protection laws.
Digital Setup: In the digital workflow a Physical Setup Model will not be created. Therefore Models
of Setup and Malocclusion are not included in the delivery. The 3D images of Malocclusion and
Setup will be sent as an Adobe 3D PDF to the email address given on the Lab Order Form. The file
size can be up to approximately 4 MB.
Manual Setup: Models of Malocclusion and Setup are included in the delivery.
Deutsche Bank AG
BLZ 300 700 10
Konto Nr. 0 655 176 600
IBAN: DE63 3007 0010 0655 1766 00
BIC/SWIFT: DEUTDEDD
USt-/VAT-ID: DE 812489284
Amtsgericht Osnabrück
Handelsregister: B 18628
Geschäftsführer:
Christoph Beyer
Thomas Boekenkamp