Thank you for choosing ROE! Please include:

SUBJECT: PATIENT NAME

MESSAGE: DOCTOR NAME, PHONE NUMBER. PLANNING SOFTWARE

Print, complete & fax this CT Order Form with each upload

Folders must be zipped. For technical support call 800 228 6663.

Submitting this data is subject to the terms and conditions of the Master Surgical Guide Agreement, which are incorporated herein by this reference.  The above referenced Placing Dentist and Restoring Dentist (collectively “Dentist”) represents, declares and agrees that the Dentist (1) is a licensed dental professional qualified to perform the dental implant procedure documented in the above case plan; (2) has or will reviewed the case plan and all relevant data related to the case plan and approve the same; (3) that the file and all relevant data provided to ROE Dental Laboratory, Inc. (“ROE”) for purposes of constructing the surgical guide is accurate and approved by the Dentist; (4) agree that ROE is not responsible for improperly fitting surgical guides when the scan appliance used was fabricated by a third party or models the Scan Appliance was constructed on are not available; (5) assumes full responsibility for both the plan and resulting surgical guide(s); and (6) that this data will be accompanied by our Work Authorization which is  made subject to the terms of the Master Surgical Guide Agreement which includes, but is not limited to, disclaimers on  all warranties and a limitation of ROE’s liability. The Customer is commissioning ROE to obtain, plan or construct the surgical guide(s) and accepts all terms and conditions established by the surgical guide manufacturer and ROE.