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Golpa All-on-4® Extended Warranty and Maintenance Program Patient Name:__________________________________________________________ Nobel Biocare and Dr. Golpa guarantee to replace any Nobel Biocare implant that fails to remain in the bone in which it is implanted. Nobel Biocare will replace free of charge the implant and Nobel Biocare restorative components placed on the implant at the time of failure with the same Nobel Biocare implant and restorative components as installed on the implant at the time of failure (the only possible changes are related to diameter and/or length). Your PMMA/Titanium bridge(s) are warrantied for a period of 5 years. Within the warranty period we will repair or replace bridges that fail due to workmanship at no charge. This period can be extended indefinitely through our Maintenance and Extended Warranty Program. Your Prettau Zirconia bridge(s) are warrantied for 15 years. Within the warranty period we will repair or replace bridges that fail due to breakage at no charge. This period can be extended indefinitely through our Maintenance and Extended Warranty Program. *Smoking, Diabetes, improper home care, and failure to maintain professional cleaning appointments voids all warranties. Your All-on-4® bridge/s and implants should receive special care and maintenance every 6 months. If you choose to participate in our voluntary Level A extended maintenance and warranty program a complete assessment of your dental implants and bridge(s) will be conducted at each re-care appointment which will include: Visual assessment of the patient; including examining the patient for signs of inflammation, bleeding, changes in probing depths, mobility, or exudate around the implant(s), and debridement of the your dental prosthesis. In addition, we will radio-graphically examine your Implant(s) to determine whether changes have occurred in bone levels. We will also conduct a careful review of your current medications, as well as a review of your health status. Golpa All-on-4® Extended Warranty and Maintenance Program The Golpa Extended Warranty and Maintenance program is designed to ensure the long-term success of your All-on-4® restoration. Due to the nature of the tissue attachment surrounding the implant(s), Dental Implants may be more susceptible to inflammation and bone loss when plaque accumulates. Proper maintenance of the your tissues will ensure longevity of the Implant(s). Your home-care routine can significantly influence Implant success. After your re-care appointment, a patient-specific homecare routine is developed for you. The purpose of your re-care maintenance appointment is to identify if there is a problem or potential problem that needs attention, and to reline your bridge(s) to insure proper fit. 6420 Medical Street Suite 101 Las Vegas, NV 89148 1-800-797-0406 1 Your initial re-care maintenance appointment is included in your treatment, and should be set for no later than 4-6 months following surgery. Participants in our extended warranty and maintenance program also have the option of replacing the bridge(s) every 5 years (PMMA/Titanium) or 15 years (Prettau Zirconia), at no charge. Level A: return to our office bi-annually for maintenance, bridge(s) replacement, and hotel is included. Level B: have your cleaning and maintenance locally, bridge(s) replacement and hotel is included. With proper care and maintenance you All-on-4® bridges can last a lifetime. Our goal is to provide you the most durable and aesthetic restorations possible. If there is ever anything we can do to ensure your oral health we will be here for you. _____ I would like to sign up for the Level A extended warranty and maintenance program to ensure the long-term success of my All-on-4® Restoration and protect the investment I have made in my Oral Health. I understand that this program has a one-time cost of $2,500.00 and will protect my restoration for life. _____ I would like to sign up for the Level B extended warranty and maintenance program to ensure the long-term success of my All-on-4® Restoration and protect the investment I have made in my Oral Health. I understand that this program has a one-time cost of $1,500.00 and will protect my restoration for life. Golpa All-on-4® Extended Warranty and Maintenance Program There are two levels of participation in the program ____ I do not wish to participate in Extended Warranty and Maintenance Program at this time. I understand the risk of complications that may arise from the improper maintenance of my restorations, and I am willing to accept these risks. Patient Name: _______________________________ Date:__________________________ 6420 Medical Street Suite 101 Las Vegas, NV 89148 1-800-797-0406 2 Office Use Only Plan Start Date:_______________________ First Maintenance Appointment Date: ____________________ Golpa All-on-4® Extended Warranty and Maintenance Program Chart # __________________________ 3 6420 Medical Street Suite 101 Las Vegas, NV 89148 1-800-797-0406