nSequence® CT Surgical Guides RX Order Form

IMPORTANT: Review disclaimer and other important information before filling and submitting form!
  • 1
  • 2
  • 3

Patient Information



Bill to Doctor Details


Supporting Clinician Details


Treatment Planning Details

*Additional fee will apply for analog record submissions

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.

*Additional fee will apply.

Date of surgery is ultimately dependent upon complete record receipt, GoToMeeting scheduling and GoToMeeting completion. Please allow 4-6 weeks for surgery scheduling.
Please input teeth numbers (note international numbering if used).

Agreement and Disclosure*

Order Requirements

  • 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)
  • Valid email address – You will receive emailed images of your case plan for approval.
If you are mailing case records to the nSequence lab, please indicate your tracking number and date of shipment below:


The cost of the nSequence CT Surgical Guides starts at $224 and includes all of the following:

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

*See Disclaimer

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