UPLOAD Click "UPLOAD" to submit DICOM and STL Files. Next, fill out and SUBMIT the form below. Dentist Name * Practice Name * Email * Patient Name / ID: * Requested Delivery Date: * MM DD YYYY Guide Type: Pilot Guided Fully Guided Bone Reduction Implant Sites (Tooth #'s) Implant Brand Implant Series Preferred Implant Diameter (if known) Preferred Implant Length (if known) Notes Terms and Conditions The Clinician understands and acknowledges that Glass Canvas Dental Studio (GCDS) is the supplier of the surgical guide ordered in this document. The circumstances in which this product is ordered and used are only under the control of the Clinician, and the Clinician assumes full responsibility for the case planning and outcome. The Clinician agrees to verify the conformity of any delivered product with their order before using it. Should the Clinician omit to perform such control or decide to use a non-conformable product, GCDS is free from any liability for the consequences of the use of such a product. The surgical guide represents only a suggestion for treatment. The Clinician must verify if the surgical plan corresponds to their preoperatively designed surgical plan prior to surgery, and assess the appropriateness of its use clinically. Provision of the surgical guide does not in any way infer or give any Clinician authorization to use the guide clinically. The Clinician is solely responsible to ensure they have the relevant experience, qualifications and/or licenses as required by law to make such a request from GCDS, and to use the provided surgical guide clinically. The Clinician is solely responsible for the actual surgery performed, regardless of the virtual planning. Any adjustments in the surgical plan in the event of a variance between the clinical situation and the virtual planning is at the sole discretion of the clinician. The liability of GCDS for real and proven damages, regardless of the gravity of the failure, is limited to the price of the product directly related to the claim. Under no circumstances can indemnity be grounded for indirect damages such as, but not limited to: loss of revenue, increases expense, loss of customers or goodwill, loss of benets or expected savings or any other financial or commercial losses which are not direct and immediate consequences of a shortcoming of GCDS in its obligations. GCDS is not responsible for any shipping delays outside of its own control. GCDS products must be used in accordance with any instructions for use provided by the manufacturer. GCDS makes no warranty, express or implied, except that all GCDS products shall be free from defects in material and workmanship. Any warranty applies only to the original buyer and is non transferrable. No amendments or modifications may be made to this document unless in writing and duly executed by an authorized representative of GCDS. The Clinician, by signing this form, understands, acknowledges and agrees to all the “terms and conditions” and requests that a surgical guide be manufactured by GCDS in accordance with their approved surgical plan. I understand my clinical obligations as per the terms and conditions above that I, the Clinician, am solely responsible for approval of the plan and the clinical outcome. * Thank you for your submission, our Digital Team will reach out to you soon to schedule a Virtual Meeting.
