![](3D"ImplantSolutionsOrderFormw-coDr_files/image007.jpg")
Implant Solution=
s, LLC
Order Form
![](3D"ImplantSolutionsOrderFormw-coDr_files/image008.gif")
Doctor Name =
&nb=
sp; =
![](3D"ImplantSolutionsOrderFormw-coDr_files/image009.gif")
Doctor Address =
&nb=
sp;
Doctor Phone Number<=
/span>
Type=
of
Credit Card &n=
bsp; _______ =
Mastercard &=
nbsp; &nbs=
p; ______
Visa
Credit Card Number &=
nbsp; &=
nbsp; &nbs=
p; &=
nbsp; &nbs=
p; &=
nbsp; &nbs=
p;
![](3D"ImplantSolutionsOrderFormw-coDr_files/image010.gif")
Expiration Date =
&nb=
sp; =
=
Security
Code
&nb=
sp;
Name on Card =
&nb=
sp;
&nb=
sp;
Credit Card Address<=
/span>
=
Doctor e-mail Address
Order
|
<=
o:p>
|
Workstation - 4561
|
$=
17,000.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Optional Module Nerve
Detection - 4564
|
$
1,500.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Optional Module 3D -=
4572
|
$
1,500.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Optional Module GonyX - 4573
|
$
1,650.00
|
|
<=
o:p>
|
Client Version - 4577
|
$
5,050.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Optional Module Nerve
Detection -4564
|
$
1,500.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Optional Module 3D -=
4572
|
$
1,500.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Optional Module GonyX - 4573
|
$=
1,650.00
|
|
<=
o:p>
|
Server Version (all Inclusiv=
e) -
4560
|
$=
29,900.00
|
|
<=
o:p>
|
Pay Per Procedure Software &=
#8211;
4583
|
$=
2,500.00
|
|
<=
o:p>
|
Pay Per Procedure Patient Ke=
ys
– 4584
|
$=
150.00
|
|
<=
o:p>
|
Co-Doctor** - 4565
|
$=
650.00
|
|
<=
o:p>
|
Training:<=
/p>
|
<=
o:p>
|
|
<=
o:p>
|
&nbs=
p;
Web-=
site
demo movies - manuals
|
<=
span
style=3D'mso-spacerun:yes'> Free
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> &nbs=
p;
2 hours over internet
|
$=
200.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> &nbs=
p;
7 hours in Wisconsin=
|
$=
500.00
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> &nbs=
p;
One day in your office
|
$ =
1,000.00
+ travel expenses
|
|
<=
o:p>
|
<=
span
style=3D'mso-spacerun:yes'> Telephone Support - US $10=
0/hr <=
st1:place
w:st=3D"on">Germany $120/hr =
|
<=
o:p>
|
|
<=
o:p>
|
=
|
<=
o:p>
|
|
<=
o:p>
|
Support Maintenance (per Mon=
th)
– 4575
|
$=
150.00
|
|
<=
o:p>
|
CT Scanning Appliance –=
; 4581
|
$=
175.00
|
|
|
<=
o:p>
|
Surgical Stint – 4585<=
o:p>
|
$=
40.00 per site<=
/o:p>
|
|
|
Total Amount Due to
Implant Solutions, LLC:
|
$
|
|
|
|
|
|
<=
/span>
Free training=
and
first two months of maintenance
contract free<=
/u> with
purchase of software!
(**does not apply to co-doctor soft=
ware)
Note:=
All sales of software are final and there will be no refunds=
or
returns.
Manufacturer’s warranties on=
ly
apply to any operational issues.
&=
nbsp; &nbs=
p; &=
nbsp; Please complete this form and fax to (715) 387-41=
00
Implant Solutions, LLC=
1000 Corporate Drive Marshfield, WI 54449 800-995-0626 Fax: 715-387-4100
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