Order Information
IMPORTANT: MAKE SURE THIS IS CORRECT. NSEQUENCE WILL NOT BE HELD RESPONSIBLE FOR INCORRECTLY INPUTTED ADDRESS.
In order to complete this case, I have provided nSequence with the following:*
Patient Identification
Referring Information
Were you referred by an NDX lab?:*
Were you referred by an implant or lab representative?:*
Treatment Planning Details
Please provide as much detail as possible so that we can schedule your treatment planning as soon as possible.
Please include the following people in the planning session:*
Bill to Doctor Details
The case will be entirely billed to this doctor.
Practice or Organization Name (if applicable):
NPI/Dental License Number:*
Supporting Clinician Details
This doctor is typically another clinician involved with the case planning, restoration and/or surgery.
Practice or Organization Name (if applicable):
NPI/Dental License Number:
Treatment Plan Information
Select arch to treatment plan:*
What type of implants are you planning on using?:*
What guided surgical instrumentation will you use?:*
Are you planning on sinus lifts/augmentation?:*
Are you planning on bone grafting?:*
Are you planning on a bone reduction?:*
*
Is nSequence fabricating the provisional(s)?:*
Would you like us to make a backup milled digital denture? (+$325/arch):*
Would you like to add a Radiology Report to your order and have the scan interpreted by a radiologist? (+$125):*
Would you like to have Chairside Assistance? (extra fee applies):*
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):*
If you’ve selected “Other” for any of the questions above, please ensure you specify the applicable details in the notes below.
Additional Treatment Plan / Notes:
Case processing agreement and disclosure*
Please complete the form entirely. All fields indicated by * or in red are required and cannot be left blank. The next prompt will instruct you on how to submit your scan data and digital photos.