nSequence® CT Surgical Guides 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.
Please input teeth numbers (note international numbering if used).

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 CT Surgical Guides starts at $275 and includes all of the following:

  • Collaborative Surgical Planning
  • Surgical Guide
  • Optional Temporary Restoration (additional costs will apply)
  • Surgical Report

If you are looking to submit a case for CT Guided Prosthetics, click here