Implant Direct LLC ScrewIndirect Introductory Offer Clinician Form

GUIDELINES FOR SCREWINDIRECT IMPLANT OFFER

  1. OFFER extended to first 2000 dentists to meet requirements.
  2. OFFER expires the earlier of March 31, 2009 or when 10,000 implants given away.
  3. OFFER limited to North American dentists placing implants from any of the 7 major implant companies including Implant Direct.
  4. Only one OFFER per dentist, dental office, group practice or partnership regardless of whether the dentist(s) practice in multiple locations. Dentists having already received an Introductory Offer from Implant Direct prior to December 31, 2008 are still eligible for this OFFER.
  5. Dentists must identify a patient to be treated with at least 4 of the 5 ScrewIndirect implants. Dentists have 30 days from the time they register for this OFFER to designate the patient.
  6. Acceptance of this OFFER represents a commitment to provide Implant Direct with radiographic evidence that least 4 of the 5 implants were inserted in a patient within 30 days of receiving the free implants. Failure to comply with this requirement will require return of the 5 ScrewIndirect implants in vials with seals intact or payment of $750, the US List Price @ $150 each. Please email the digital radiograph to indirectoffer@implantdirect.com or fax a legible copy to 661-705-4920.
Clinician Name:
Email Address: Phone:

Implant System Used:

Implant Direct Customer Prior To December 2008
Implant Direct Nobel Biocare Zimmer Dental Straumann
Other: 3I Astra BioHorizons

Fax copy of invoice showing implant purchase from one of these competitor companies.
Patient Name or Number:

If Patient not yet selected, complete Form and submit name prior to product shipment

Treatment Planned

Lower Jaw Upper Jaw
Immed. Insertion Fully Edentulous Immed. Insertion Fully Edentulous
Patient Sex: M     F Patient Age: Proposed Date Of Surgery:

I have read and agree to abide by these guidelines for receipt of this free ScrewIndirect implant offer.