nSequence® Guided Prosthetics® RX Order Form

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Biohorizons dentsply Sirona 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



Bill to Doctor Details


Restorative Clinician Details


Treatment Planning Details

nSequence uses the manufacturer's latest version of their fully guided surgical kits.

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.

Date of surgery is ultimately dependent upon complete record receipt, GoToMeeting scheduling and GoToMeeting completion. Please allow 4-6 weeks for surgery scheduling.

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. Chairside assistance is dependent upon technician availability once the case plan has been approved by the clinician.

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/Bone Cut Verification Guide
  • Tissue Gasket
  • 2 Lucitone® Long Term Provisionals
  • Surgical Report