nSequence | CT Guided Prosthetics RX Order Form

PATIENT AND DOCTOR INFORMATION
All fields indicated by * or in red are required.

Patient Information

Gender*: Male Female

Is this a University or Hospital?*: Yes No

Bill to Doctor Details

Ship to Doctor Details

Is the shipping address same as the billing address? *: Yes No

Restorative Clinician Details

Who is the restorative doctor for this case?*: I am the restorative doctor I am the surgeon working with a different restorative doctor

ORDER INFORMATION
All fields indicated by * or in red are required.

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

Approval Details

Select how you would like to have your case approved:*: Please email images for case approval (valid email required). I would like to approve my case with a live consult session.

CASE PROCESSING
All fields indicated by * or in red are required.

Agreement and Disclosure*

Agreement Disclosure*: By checking this box, I certify that the patient is financially committed to this treatment plan. I agree that if I choose to cancel the case, once the plan has been presented, there will be a $300/per arch non-refundable fee for the nSequence Guided Prosthetics case. If the case is reinstated within 90 days from cancelation, the fee can be reapplied toward the total cost of the case. I am aware that the total case cost of the nSequence Guided Prosthetic will be charged if I choose to cancel the case once the plan has been approved and production begins. I understand if clinical photos and shade information are not provided on or before the consultation, my case may be delayed. I agree that if the nSequence case is approved for a rush fee, there will be a $1,250/per arch charge for the nSequence Guided Prosthetics case. Credit cards on file will be charged once the case ships.

Order Requirements

Order Requirements*: In order to complete this case, I have provided nSequence with the following:*

Clinical digital photos of patient
Upper and lower conventional VPS impressions/poured models OR STL digital impressions
Blu-Mousse® bite following nSequence Records 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:

Guided Prosthetics Order

nSequence^® Guided Prosthetics^® RX Order Form

Patient Information

Bill to Doctor Details

Ship to Doctor Details

Restorative Clinician Details

TREATMENT PLAN
All fields indicated by * or in red are required.
Treatment Planning Details

Approval Details

Agreement and Disclosure*

Order Requirements

Guided Prosthetics Order

nSequence® Guided Prosthetics® RX Order Form

Patient Information

Bill to Doctor Details

Ship to Doctor Details

Restorative Clinician Details

TREATMENT PLAN All fields indicated by * or in red are required. Treatment Planning Details

Approval Details

Agreement and Disclosure*

Order Requirements

nSequence^® Guided Prosthetics^® RX Order Form

TREATMENT PLAN
All fields indicated by * or in red are required.
Treatment Planning Details