nSequence® CT Surgical Guides RX Order Form

Please complete the entire form below. All fields indicated by * are required. 
 

Disclaimer:

Please make sure that your case is ready to move forward at the time of RX submission. If you choose to place your case on hold directly after a GoToMeeting, a deposit of $100.00 for surgical guides with 1-3 implant sites or $275.00 for surgical guides with 4-8 implant sites will be charged per arch to maintain the hold status. When you are ready to remove the hold and proceed forward, the deposit will be applied toward the cost of your case. The deposit is non-refundable if your case is canceled. All approved rush cases will have a rush fee of 33.3% of the surgical guide cost applied to the order. Anatomical models are no longer included with surgical guide orders except for bone foundation guides. However, you may purchase a model separately for an additional cost of $50.00 for 1,2,3 unit guides and $395.00 for full arch guides. 

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

Important Information to Review:

Before you begin completing the order form below, please review the CT Guided Scan Protocol and Scan Quality tips. You will also need to have the following in order to process your case:

  • Scan of patient (with Blu-Mousse bite in place at MIP or desired vertical opening)
  • Scan of denture with markers (dual scan protocol - if applicable)
  • Upper and lower impressions or models (optical scan conversion - if applicable)
  • Patient photos (digital)

CT Guided Scan Protocol:

Scan Quality:

Before submitting your case, check that all your scans adhere to the following guidelines:
  • Scan field of view: Make sure no part of the desired arch to be treatment planned is cut off, there is no patient movement and a scan appliance was used.
  • Scan resolution: Minimum of 0.3 voxel is recommended. The smaller the number, the better (ex: 0.2, 0.1, etc.).
  • Scan format: Please send all files in DICOM format.


Order Information

 

IMPORTANT: MAKE SURE THIS IS CORRECT. NSEQUENCE WILL NOT BE HELD RESPONSIBLE FOR INCORRECTLY INPUTTED ADDRESS.








Failure to complete these steps will result in delays to your case.

Patient Identification

 

Referring Information

 



Treatment Planning Details

Please provide as much detail as possible so that we can schedule your treatment planning as soon as possible. 







Bill to Doctor Details

The case will be entirely billed to this doctor. 


Supporting Clinician Details

This doctor is typically another clinician involved with the case planning, restoration and/or surgery. 


Treatment Plan Information

 










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.
Please input teeth numbers (note international numbering if used).


If you’ve selected “Other” for any of the questions above, please ensure you specify the applicable details in the notes below.


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.