Straumann174; CARES174; Scan Shape.（Straumann174;）.pdfVIP

Straumann® CARES® Scan Shape. CARES® Screw-retained Bars Bridges (SRBB) Order Form. INSTRUCTIONS For internal use only 1. Please fill out all applicable fields and check boxes before printing the form 2. In order to process your order smoothly, we require ALL information on this form to be filled in correctly Project No: 3. If you require any help with this form, please contact our Technical Support Team at 866/531 7365 Date received: 4. It is essential that you send us your diagnostic wax-up in order for us to design a well-fitting prosthesis for you Operation: 5. Your signature is required on the back of this form to complete the order Customer details Name of Business Straumann® Customer No. Contact Person Patient (initials or ID# only) Address City State / Zip code Phone Email Address Fax TYPE OF PROSTHESIS REqUIREd (please check one)  CARES® CARES® CARES® CARES® CARES® CARES® CARES® CARES®  CARES® CARES® Screw- Dolder® Dolder® Dolder® Dolder® Ackermann® Round Bar MP-Clip CARES® Basic Fixed Bar Advanced Milled Bar LOCATOR®* Retained U-shape, U-shape, Egg-shape, Egg-shape, Bar Fixed Bar