By signing or sending this Rx form (or a substitute thereof), to Khzam Dental Lab, I agree to abide by all terms and policies listed below.


This Customer Agreement (“Agreement”) is made as of the date set forth on the reverse hereof and by and between Khzam Dental Lab (“Company”) and the customer set forth on the reverse hereof (“Customer”). The Company and the Customer do hereby agree as follows:
1. Payment Terms. Full payment, as set forth on the Company’s current price sheet for all products, work, services or shipments requested by the Customer pursuant to each order placed by the Customer shall be due no later than the 30th day after the date of the statement date (the “Due Date”) (i.e., on a Net 30 basis), regardless of when actually received by Customer. Any remaining, unpaid balances existing past the Due Date shall be considered past due.
2. Past Due Amounts. On any past due balances, Customer agrees to pay a late monthly charge equal to two percent (2%) of any such balance. This late charge will accrue on a pro-rata basis during each 30 day period starting on the Due Date and continuing until the unpaid past due balance is paid in full. No late charges shall accrue during the first thirty (30) days from the date of the statement (net 30 days). Unless elected otherwise by the Company, any promotional discounts will be void if the invoice total is not paid when due; and any and all future shipments to the Customer shall be on a C.O.D. basis only, as to the entire outstanding balance, until the Customer’s entire outstanding balance and any late charges are paid in full.


Due to increases in materials and labor we are forced to charge for remakes. We can not absorb the cost of any remake that is the result of an inaccurate or destroyed model. If a patient changes their mind during or after production of any case, you will incur the cost of any and all changes. Once a case has been completed, any changes made will be regarded as a new case.
A frame is only as good as the model that it was made on. It is the only guideline we have, therefore if the model is an accurate representation of the patient’s mouth then the frame will fit exactly same way in the mouth as on the model. If the model, however, is not accurate, then the frame will fit the model but not the patient’s mouth. We will only be held responsible for the fit of the frame on the model that it was made on.
1. KHZAM DENTAL LAB warranty covers:
the repair or replacement of a fixed or removable prosthetic.Implant.

1. Prosthesis must be inserted by a licensed practicing dentist.
2. Patient must adhere to semi-annual dental maintenance (cleaning and exam) in the office of a licensed practicing dentist.
3. The maintenance schedule on this certificate must be documented by the attending dentist each visit to validate this warranty.
4. Dental prosthetic must be returned with model work in order for the credit to be issued.
1. Cash refund for prosthesis.
2. Cost incurred for removal or insertion.
3. Incidental or consequential damages; including inconvenience, lost wages, chairtime, or pain and suffering.
4. Repairs resulting from accident, neglect, abuse, failure of supportive tooth or tissue structures, improper adjustments or dental hygiene.
5.Khzam Dental Lab is not liable for any fixed prosthetic over 5 (five) units or All on four Hybird zirconia bridges and all Implant cases.or any removable prosthetic that has not been appropriately fitted prior to process.
6. Repairs, relines, temporaries, implants, immediate dentures or partials, and appliances partially or completely fabricated by another lab other than Khzam Dental Lab. ***Warranty begins on delivery date. This warranty is in lieu of all other warranties, whether expressed or implied, and may not be modified by any agent, employee, representative or distributor of Khzam Dental Lab. ***All warranty terms and conditions are subject to change without notice. ***All prices are subject to change without notice and are quoted as one stage. Some products are subject to additional fees, e.g., bridge connectors, additional implant parts , multiple stages, and metal surcharges. ***All discounts will be applied to promoted product and current pricing. Discount terms are subject to change without notice.