1. v v v 1. Customer information 2. Please check for enclosed items
( ENGLISH CAPITAL LETTER )
Company name
VITA MEDICA
Patient name
KOBIAŁKA AGNIESŁKA
Delivery address
Lot Number :
OSSTEM Germany : (독일법인)
Customer Code :
Phone number :
2. Please check for enclosed items  v
Case Description: # of units _1__ □ Single □ Splint
□ Order Sheet □ Impression (Mandibular) □ Impression (Maxillary)
□ Check Bite ※ Please send impression (2 sides) with Tray.
□ Bite Registration □ Fixture Lab Analog ( )ea □ Diagnostic Wax-up (multi cases only)  v  v
Name of Sales in Charge
Signature
3. Implant information
Fixture
Abutment (Titanium)
Tooth No.
Fixture diameter
Abutment type (Check)
Final crown (Check)
Abutment Margin position (Check)
Sub default dimension : -0.5~-1.0 mm
(Ex:14)
(Ex : TSIII)
(Ex:Ø4.5)
Supra default dimension : +0.5~+1.0 mm
Type √ 46
TS III
4.0
Hex  v
N-Hex
PFM
Zirconia
Full Metal
Sub
Equal
Supra 2 6 7 8 9 10

2. ※ Please check Design with Adobe Reader prior to milling process asap.
4. Parallel abutments
(If final restorations will be splinted, the abutments must be designed to be parallel.)
Abutment Tooth # Pontic Tooth #___________
5. Case Design
6. Abutment Emergence width
※ Please check Design with Adobe Reader prior to milling process asap.
Taper Preference (A°) 2° 4° 6°
Specify
Margin Type
Bevel
Moderate Chamfer V
Deep Chamfer mm
① Follow soft tissue contours (No change on soft tissue model)
v ② Slight soft tissue modification (Soft tissue may be slightly blanching)
③ Ideal emergence profile (Soft tissue re-contouring)
Ver2 A°
7. Additional Instructions
( ENGLISH CAPITAL LETTER )  v
Bevel
(Knife Edge)
8. Ordered by
( ENGLISH CAPITAL LETTER )
Name :
addresss :
Phone number :
Moderate Chamfer
(0.3/0.4/0.5)
Deep Chamfer
(0.6 and above)
Date
Signature