By completing this “Pacific DDS, LLC Prescription Form”, I hereby approve and fully agree to this Agreement. The referenced Placing Dentist and Restoring Dentist (collectively “Dentist”) represents, declares and agrees that the Dentist (1) is a licensed dental professional qualified to perform the dental implant procedure documented in the related case plan; (2) has reviewed the case plan and all relevant data related to the case plan and approve the same; (3) that the file and all relevant data provided to Pacific DDS, LLC (“Company”) for purposes of constructing the surgical guide is accurate and approved by the Dentist; (4) agree that Company is not responsible for improperly fitting surgical guides when related stone models are not available; (5) assumes full responsibility for both the plan and resulting surgical guide(s); and (6) that this Work Authorization is being made subject to the terms of the Surgical Guide Agreement which includes, but is not limited to, disclaimers on all warranties and a limitation of Company’s liability. By submitting this Work Authorization, the Dentist is commissioning Company to obtain or construct the surgical guide(s) and accepts all terms and conditions established by the surgical guide manufacturer and Company.