New Practice Program
To assist you in establishing your new practice and to make your first 5 years more successful, Mentor is pleased to offer you special product savings, patient education materials, and marketing and practice support. Please complete and sign this credit application in full to be considered for open account status. If the information supplied is incomplete or found to be incorrect, this may delay processing of the application and could affect prompt delivery of products or services. In addition, inaccurate information may void your eligibility for participation in this program. I, (We) submit the following information in applying for an open account: (required info)
Participation in this program is subject to eligibility criteria and Mentor's acceptance of your application.

Physicians are eligible once in a lifetime and must have received a new Mentor bill-to account number. Breast Implants are not redeemable for cash, and are non transferable. Eligibility expires five years after the sign-up date.

Eligible products, services, and pricing are subject to change. All non-consignment orders will be entered as Easy Orders by default. Mentor Easy Order form not required.

1.Easy-Order Request: All products ordered through the Easy-Order Program are subject to the terms of this Agreement and Mentor's standard invoice terms. If a Purchase Order Number ("P.O.") is required for billing, the P.O. must be provided at the time of order.
2.Easy-Order Product Return: Customer agrees to return to Mentor all unused products ordered through the Easy­ Order Program immediately after surgery. Unused products must be received at Mentor's Coppell, TX distribution center within 30 days of the Easy-Order shipment date.
3.Billing: Customer shall be invoiced for all items not received by Mentor within 30 days from the initial Easy-Order shipment date from Mentor to Customer and for any items that when received are destroyed, damaged, or otherwise not in saleable condition, and Mentor or its affiliate will retain title to those items. If a P.O. is required by Customer for payment, Mentor will reference the P.O. provided at the time of order on the invoice.
4.Payment: Customer agrees to pay all invoices resulting from an Easy-Order billing within Mentor's standard payment terms.
5.Term/Termination: This agreement becomes effective upon the date of Mentor signature and will remain effective indefinitely unless terminated by either party. Either party may terminate this agreement, with or without cause, upon fifteen (15) days written notice to the other party. Upon termination of this agreement, all outstanding products ordered through the Easy-Order Program would be immediately invoiced to Customer.

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Please attach a copy of your W-9 form.

A W-9 is required for all new NPP registrations. Please ensure that the name on the W-9 matches the "Business/Practice/Hospital/DBA name" entered above. If a W-9 is not attached, Mentor Customer Service will contact you to obtain a copy before fulfilling your request.

 


Signature & MentorDirect.com Registration


Sign this form by entering your email address and check the below box. Your signature on this form confirms your authorization for Mentor Worldwide LLC to keep this information on file.

By signing this form you certify that all information provided is complete and accurate. Your MentorDirect.com account will be activated upon approval of this application and the email address you provide will be your username. Once your application is approved you will receive a MentorDirect.com welcome email with login instructions.

I give permission to Mentor to run my credit and enroll me into the New Practice Program.

Entering the above information and checking this box is your electronic signature. By this signature, you are agreeing to the foregoing terms and conditions of the New Practice Program.

If representations made by the buyer in this credit application are subsequently found incorrect or incomplete, the right is reserved to reject the application and to negate any obligation to proceed with any merchandise, and to bill buyer for the full value of any products and services previously provided under this program. (1) Buyer recognizes seller’s terms as stated on its invoice and acknowledges and authorizes a service charge of 1-1/2% per month (18% annual) on any past due amounts. (2) Seller shall have the right to (A) declare the entire amount due, (B) in the event of default customer agrees to pay attorney and or collection agency fees not exceeding 25%, (C) to change the terms of the account from time to time (consistent with applicable law) to be effective not less than 30 days after given written notice, (D) to limit the amount of credit extended under this account or terminate the account, upon given written notice thereof; but seller may avail itself of the terms of this agreement until full payment of the entire balance with finance charge to date of payment has been received. (3) In submitting this application for credit, buyer authorizes seller to investigate his/her credit record.

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WARNING:

  • Breast implants are not considered lifetime devices. The longer people have them, the greater the chances are that they will develop complications, some of which will require more surgery.

  • Breast implants have been associated with the development of a cancer of the immune system called breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This cancer occurs more commonly in patients with textured breast implants than smooth Implants, although rates are not well defined. Some patients have died from BIA-ALCL.

  • Patients receiving breast implants have reported a variety of systematic symptoms such as joint pain, muscle aches, confusion chronic fatigue, autoimmune diseases and others. Individual patient risk for developing these symptoms has not been well established. Some patients report complete resolution of symptoms when the implants are removed without replacement.

Caution: US law restricts this device to sale by or on the order of a physician.

The sale and distribution of Mentor Breast Implant Devices are restricted to users and/or user facilities that provide information to patients about the risks and benefits of the device prior to its use in the form and manner specified in approved labeling to be provided by Mentor Worldwide LLC.

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MENTOR® MemoryGel® Breast Implants, MENTOR® MemoryShape® Breast Implants, and MENTOR® Saline-filled Breast Implants are indicated for breast augmentation in women (at least 22 years old for MemoryGel® Implants and MemoryShape® Implants, and 18 years old for Saline Implants) or for breast reconstruction. Breast implant surgery should not be performed in women with active infection anywhere in their body, with existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions, or who are currently pregnant or nursing.

Breast implants are not lifetime devices and breast implantation may not be a one-time surgery. The most common complications for breast augmentation and reconstruction with MemoryGel® Implants include any reoperation, capsular contracture, and implant removal with or without replacement. The most common complications with MemoryShape® Implants for breast augmentation include reoperation for any reason, implant removal with or without replacement, and ptosis. The most common complications with MemoryShape® Implants for breast reconstruction include reoperation for any reason, implant removal with or without replacement, and capsular contracture. A lower risk of complication is rupture. The health consequences of a ruptured silicone gel breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture. The most common complications with MENTOR® Saline-filled Implants include reoperation, implant removal, capsular contracture, breast pain, and implant deflation.

For MemoryGel® Implants, patients should receive a copy of Important Information for Augmentation Patients about MENTOR® MemoryGel® Breast Implants or Important Information for Reconstruction Patients about MENTOR® MemoryGel® Breast Implants. For MemoryShape® Implants, patients should receive a copy of Patient Educational Brochure – Breast Augmentation with MENTOR® MemoryShape® Breast Implants or Patient Educational Brochure – Breast Reconstruction with MENTOR® MemoryShape® Breast Implants, and a copy of Quick Facts about Breast Augmentation & Reconstruction with MENTOR® MemoryShape® Breast Implants. For MENTOR® Saline-filled Implants, patients should receive a copy of Saline-Filled Breast Implants: Making an Informed Decision. Your patient needs to read and understand the information regarding the risks and benefits of breast implants, with an opportunity to consult with you prior to deciding on surgery.

The ARTOURA™ Breast Tissue Expander or CONTOUR PROFILE® Breast Tissue Expander can be utilized for breast reconstruction after mastectomy, correction of an underdeveloped breast, scar revision, and tissue defect procedures. The expander is intended for temporary subcutaneous or submuscular implantation and is not intended for use beyond six months. Do not use the ARTOURA™ Tissue Expander nor CONTOUR PROFILE® Tissue Expander in patients where an MRI may be needed. The device could be moved by the MRI causing pain or displacement, potentially resulting in a revision surgery. The incidence of extrusion of the expander has been shown to increase when the expander has been placed in injured areas.

For detailed indications, contraindications, warnings, and precautions associated with the use of all MENTOR® Implantable Devices, which include MENTOR® Saline-filled Implants, MemoryGel® Implants, MemoryShape® Implants, ARTOURA™ Expanders, and CONTOUR PROFILE® Expanders, please refer to the Product Insert Data Sheet provided with each product or visit www.mentorwwllc.com.