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.  
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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


Supporting Clinician Details


Referring Information


Treatment Planning Details

Treatment Plan Information

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.

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.

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


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