nSequence® Guided Prosthetics® RX Order Form

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

 

Gender:*

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