Implant replacement service Return form Please note: The Implant Replacement Service (IRS) program should be utilized for situations where the sterile barrier of the implant has been compromised (e.g., opened in error, dropped) or in cases where the implant was placed and promptly removed within 24 hours (e.g., failure to achieve primary stability, spinner). For implants fractured at placement or possible osseo failures (in place for more than 24 hours) contact customer support at 800 322 5001. Please print legibly or fill form out electronically; a printed hard copy must be returned with the implant(s). Implant replacement: There is a maximum of 10 no-charge implant replacements per year. The $100.00 per implant replacement fee will be charged once the maximum has been reached. Shipping instructions: 1) Sterilize the implants to be returned. As part of the IRS program, final abutments not removed will not be replaced and cannot be returned. 2) Complete this form, print out, and enclose with returned product(s). 3) Please return in a traceable manner (e.g., FedEx, UPS, etc.) to the following address: Nobel Biocare USA, LLC., ATTN: Returns Department, 22715 Savi Ranch Pkwy., Yorba Linda, CA 92887 Name Account number Phone number Fax number Address City State Contact person Email address Returned implants Material # Zip Requested implants* Lot/Batch # Quantity Description Material # Quantity *Additional cost differences between the returned implants and the replacement implants will be the responsibility of the customer. For office use only Date CSR Date received Material # Lot/Batch # EDD Date inspected Inspected by Quantity Comments Description Total Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887 Phone 714 282 4800; Toll free 800 993 8100; Customer Support 800 322 5001 ©2014 Nobel Biocare USA, LLC. All rights reserved. www.nobelbiocare.com MKT-3005, Rev. 04 (06/14, GMT 35863) Disp./Code