nSequence | CT Guided Prosthetics RX Order Form

You can save $500 by adding the final restoration to your order! To add the final restoration, please select one of the following 5 options (bundled cost includes nSequence Guided Prosthetic Kit of $3,300 + final restoration at discounted price). If you do not need the final restoration, please select no and you will only be charged the $3,300 base fee:*

OFFERING OEM TITANIUM BARS FOR OUR PREFERRED PARTNERS :

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

Screw-Retained Hybrid Prosthetic acrylic denture with acrylic teeth and OEM (original-on-original) milled titanium bar ($5,650)
Screw-Retained Hybrid Monolithic Zirconia (no cutback) ($6,300)
Screw-Retained Hybrid Monolithic Zirconia (anterior cutbacks) ($6,810)
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)
No final restoration is needed ($3,300)

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

Patient Information

Gender:*

MaleFemale

Bill to Doctor Details

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

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

Are you sending in upper and lower conventional VPS impressions/models OR STL digital impressions? Please check one:*

Conventional VPS impressions/models
STL digital impressions

Would you like us to make a temporary backup 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.

How would you like your surgical report delivered?:*

Print
Digital
Both

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. Customary PPE must be provided by the office for the chairside technician covering the case. 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.

Promo Code:

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

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. I agree that bundled cases (includes the final restoration) are non-refundable and must be redeemed within 9 months from the day of surgery. I agree that if I choose to cancel the case, once the consultation has been scheduled, there will be a $1,000/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 Prosthetics will be charged if I choose to cancel the case once the consultation is complete 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.

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 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)

Tracking Information: 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

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

Approval and Shipping Details

Agreement and Disclosure*

Order Requirements

The cost of the nSequence Guided Prosthetics Kit is $3,300 and includes all of the following:

Guided Prosthetics Order

nSequence® Guided Prosthetics® RX Order Form

Patient Information

Bill to Doctor Details

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

Approval and Shipping Details

Agreement and Disclosure*

Order Requirements

The cost of the nSequence Guided Prosthetics Kit is $3,300 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