Send a Case > CT Guided Prosthetics RX Order Form

nSequence^® Guided Prosthetics^® RX Order Form

IMPORTANT: Review disclaimer and other important information before filling and submitting form!

You can save $500 by adding the final restoration to your order! To add the final restoration, please select one of the following 8 options (bundled cost includes nSequence Guided Prosthetic Kit of $3,250 + final restoration discounted price). If you do not need the final restoration, please select no and you will only be charged the $3,250 base fee:*

No final restoration is needed
Screw-Retained Hybrid Prosthetic acrylic denture with acrylic teeth and authentic Nobel Biocare bar ($5,900)
Screw-Retained Hybrid Prosthetic acrylic denture with acrylic teeth and authentic Straumann bar ($5,500)
Screw-Retained Hybrid Prosthetic acrylic denture with acrylic teeth and milled titanium bar ($5,350)
Screw-Retained Hybrid Monolithic Zirconia (no cutback) ($6,150)
Screw-Retained Hybrid Monolithic Zirconia (anterior cutbacks) ($6,660)
Screw-Retained Hybrid Nano-Ceramic Prosthetic ($6,660)
Screw-Retained Hybrid Copy-Milled Prosthetic with individual solid Zirconia crowns (anterior six are cutback and layered on the facial) ($7,950)

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

Patient Information

Gender:*

MaleFemale

Bill to Doctor Details

Supporting Clinician Details

Referring Information

Were you referred by an NDX lab?:*

Yes
No

Were you referred by an implant or lab representative?:*

Yes
No

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

Please include the following people in the planning session:*

My specialist involved with this case
My implant coordinator
My dental lab representative
My implant sales representative
My patient
No one else but me

Treatment Plan Information

Select arch to treatment plan:*

Maxilla
Mandible

What type of implants are you planning on using?:*

What guided surgical instrumentation will you use?:*

Preferred articulator:*

Are you planning on sinus lifts/augmentation?:*

Yes
No

Are you planning on bone grafting?:*

Yes
No

Are you planning on a bone reduction?:*

Yes
No
Not sure, nSequence can recommend

Are you planning on extractions?:*

Yes
No

Is nSequence fabricating the provisional(s)?:*

Yes
No

Would you like us to make a backup milled digital denture? (+$325/arch):*

Maxilla
Mandible
No

Would you like to add a Radiology Report to your order and have the scan interpreted by a radiologist? (+$125):*

Yes
Yes, please rush (+$35)
No

NOTE: 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.

Would you like to have Chairside Assistance? (extra fee applies):*

Yes
No

NOTE: 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. To expedite your request for Chairside Assistance, please complete this form.

Desired implant location(s):*

Additional Treatment Plan / Notes:

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

Approval and Shipping 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.

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

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

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

Agreement and Disclosure*

By checking this box, I certify that the patient is financially committed to this treatment plan.

By checking this box, I agree that bundled cases (includes the final restoration) are non-refundable and must be redeemed within 9 months from the day of surgery.

By checking this box, I agree that if I choose to cancel the non-bundled case once consultation has been scheduled there will be a $1,000.00/per arch non-refundable deposit for the nSequence Guided Prosthetics case (fully guided nSequence case). If the case is reinstated within 90 days from cancelation, the deposit can be reapplied toward the total cost of the case.

By checking this box, I am aware that the total case cost of bundled and non-bundled cases will be charged if I choose to cancel the case once consultation is complete and production begins.

I understand if clinical photos and shade info are not provided on or before consultation, my case may be delayed.

By checking this box, I agree that if the nSequence case is approved for a rush fee, there will be a $1,250.00/per arch charge for the nSequence Guided Prosthetics case (fully guided nSequence case).

Order Requirements

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

This complete RX with all information and thorough instructions
Clinical digital photos of patient with shade tab (if nSequence is to make the provisional restoration)
Upper and lower conventional VPS impressions or poured models sent via mail or local pickup
Blu-Mousse bite in MIP using nSequence protocol via mail or local pickup
STL digital impressions
Patient scan in DICOM format (upload after submission of this form)
Denture scan in DICOM format (upload after submission of this form)
Patient scan in DICOM format (will be sent on CDs)
Denture scan DICOM format (will be sent on CDs)

The cost of the nSequence Guided Prosthetics Kit is $3,250 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
Long Term Provisional Prosthesis with milled integrated reinforcing bar
Clear Duplicate
Surgical Report

Guided Prosthetics Order

nSequence® Guided Prosthetics® RX Order Form

Patient Information

Bill to Doctor Details

Supporting Clinician Details

Referring Information

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

Treatment Plan Information

Approval and Shipping Details

Agreement and Disclosure*

Order Requirements

The cost of the nSequence Guided Prosthetics Kit is $3,250 and includes all of the following:

nSequence^® Guided Prosthetics^® RX Order Form

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