Requisition Form

TERMS & CONDITIONS AND SOP FOR AMGRAFT SAMPLE DISTRIBUTION

PURPOSE:
To collect clinical cases, documentation, videos, and recruit potential key opinion leaders/speakers.

CRITERIA OF ELIGIBLE CANDIDATES:
1. Licensed dentist practitioner (General Practitioner, Periodontics, Implantologist, Oral Surgeon, Orthodontics, Prosthodontics)
2. Willing to document clinical procedures comprehensively
3. Commit to submit clinical documentation (pre, intra, and post-operative)

SAMPLE DISTRIBUTION PROCEDURE:
1. Doctor fills out the requisition form completely
2. Verification of requisition form by Sante Maison team
3. Approval or rejection is communicated within 3 working days
4. Arrange shipment and delivery of samples

DOCUMENTATION REQUIREMENTS:
1. Pre-operative imaging (CBCT/X-ray/Photos)
2. Documentation during the grafting procedure (photos/videos)
3. Follow-up documentation (1-week, 1-month, 3-month intervals)

CLINICAL DECK / REPORT SUBMISSION:
1. Doctors must submit a clinical deck/report detailing case outcomes
2. Doctors are willing to allow anonymous case publication by Sante Maison and associates

COMPLIANCE & ETHICAL RESPONSIBILITY:
1. Doctors must ensure patient consent for documentation and case sharing
2. Doctors must comply with medical ethics and confidentiality regulations

I acknowledge that I have read and accept the Terms & Conditions stated above.