Contact information:

3Shape Implant Studio

Surgical Report

Order Details FOR APPROVAL

Patient Name:

Client Order Reference: 12345_20230916_2051_45_423

Creation Date: 9/16/2023 9:31:27 PM

Created by: Default user _______________

(121d801a-4663-4551-9172-fb9edc93371b) Approved by

Lower Jaw Upper Jaw

Implant information
Implant position (FDI) 25 27 45
Manufacturer Hiossen Hiossen Hiossen
Type ETIII Mini 3.5x10.0 ETIII Regular 4.0x8.5 ETIII Mini 3.5x10.0
Order number ET3M3510 ET3R4008 ET3M3510
Length, mm 10 8.5 10
Diameter (Ø), mm 3.5 4 3.5
Color Yellow Green Yellow

Implant information
Implant position (FDI) 47
Manufacturer Hiossen
Type ETIII Mini 3.5x8.5
Order number ET3M3508
Length, mm 8.5
Diameter (Ø), mm 3.5
Color Yellow

Limitation of Liability: Page 1

This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
 Implant Information

Implant position (FDI) 25

Manufacturer Hiossen

Type ETIII Mini 3.5x10.0

Order number ET3M3510

Length, mm 10

Diameter (Ø), mm 3.5

Color Yellow

Safety zone - apical distance 2.0

Safety zone - radial distance 1.5

Buccal Mesial Lingual Distal

M D

Limitation of Liability: Page 2

This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
 Implant Information

Implant position (FDI) 27

Manufacturer Hiossen

Type ETIII Regular 4.0x8.5

Order number ET3R4008

Length, mm 8.5

Diameter (Ø), mm 4

Color Green

Safety zone - apical distance 2.0

Safety zone - radial distance 1.5

Buccal Mesial Lingual Distal

M D

Limitation of Liability: Page 3

This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
 Implant Information

Implant position (FDI) 45

Manufacturer Hiossen

Type ETIII Mini 3.5x10.0

Order number ET3M3510

Length, mm 10

Diameter (Ø), mm 3.5

Color Yellow

Safety zone - apical distance 2.0

Safety zone - radial distance 1.5

Buccal Mesial Lingual Distal

M D

Limitation of Liability: Page 4

This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
 Implant Information

Implant position (FDI) 47

Manufacturer Hiossen

Type ETIII Mini 3.5x8.5

Order number ET3M3508

Length, mm 8.5

Diameter (Ø), mm 3.5

Color Yellow

Safety zone - apical distance 2.0

Safety zone - radial distance 1.5

Buccal Mesial Lingual Distal

M D

Limitation of Liability: Page 5

This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.