nSequence® Guided Prosthetics® RX Order Form

IMPORTANT: Review disclaimer and other important information before filling and submitting form! Our definitive restorations are backed by the following Warranties. To learn more about our Definitive Prosthetic options, view them here! To discuss your options with a Clinical Sales Specialist, contact us now!
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OFFERING OEM TITANIUM BARS FOR OUR PREFERRED PARTNERS :

Biohorizons dentsply Sirona keystone Dental Neodent Noble Biocare
StraumannZimmer Biomet

NOTE: Cases from other implant companies will not be OEM unless customer calls and requests it. Other OEM bar options may result in additional charges







Patient Information

 

Gender:*

Bill to Doctor Details

 

Supporting Clinician Details

 
 



Treatment Planning Details













Standard turnaround time to forward scan to radiologist is 5 to 7 business days and rush cases are completed by the end of the next business day for an additional fee.



DUE TO NATIONWIDE TRAVEL RESTRICTIONS, CHAIRSIDE SUPPORT MAY NOT BE AVAILABLE IN YOUR AREA AT THIS TIME. NDX NSEQUENCE IS CLOSELY MONITORING THESE RESTRICTIONS AND SHOULD YOU BE IMPACTED, WE WILL CONTACT YOU IMMEDIATELY TO DISCUSS POSSIBLE ALTERNATIVES.

nSequence highly recommends chairside assistance for 1st time users to ensure ease of delivery. Our technicians are comprehensively trained on the best way to proceed with the nSequence Guided Prosthetics System. Customary PPE must be provided by the office for the chairside technician covering the case. To expedite your request for Chairside Assistance, please complete this form.


Promo codes cannot be applied in conjunction with any other offers or discounted pricing.

Approval and Shipping Details


Make sure this is correct. nSequence will not be held responsible for incorrectly inputted address.

Please do not schedule your patient until your ship date has been confirmed with our office.

Agreement and Disclosure*

Order Requirements

  • Clinical digital photos of patient
  • Upper and lower conventional VPS impressions/poured models OR STL digital impressions
  • Blu-Mousse® bite in MIP using nSequence protocol
  • Patient scan in DICOM format (upload after submission of this form or sent on CDs)
  • Denture scan in DICOM format (upload after submission of this form or sent on CDs)
If you are mailing case records to the nSequence lab, please indicate your tracking number and date of shipment below:
CT Guided Prosthetic  

The cost of the nSequence Guided Prosthetics Kit is $3,300 and includes all of the following:

  • Collaborative Surgical Planning
  • Anatomical Model
  • Bone Foundation Guide (Reduction Guide)
  • Surgical Guide
  • Start Bite, Angle Rotation Guide and Prosthetic Bite Guide
  • Tissue Gasket
  • 2 Lucitone® Long Term Provisionals
  • Surgical Report