nSequence | CT Surgical Guides RX Order Form

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

Patient Information

Gender*: Male Female

Bill to Doctor Details

Ship to Doctor Details

Is the shipping address same as the billing address? *: Yes No

Restorative Clinician Details

CASE PROCESSING
All fields indicated by * or in red are required.

Agreement and Disclosure*

Agreement and Disclosure*: By checking this box, I certify that the patient is financially committed to this treatment plan. I agree that if I choose to cancel the case, after the digital planning has been completed, there will be a $100/per arch non-refundable fee for surgical guides with 1-3 implant sites or a $275/per arch non-refundable fee for surgical guides with 4-8 implant sites charged to my account. 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 will be charged if I choose to cancel the case once the digital planning is complete and production begins. I agree that if the nSequence case is approved for a rush fee, there will be a fee of 33.3% of the surgical guide cost applied to the order. If applicable, I understand if clinical photos and shade information are not provided, my case may be delayed. Should your case require a bone foundation guide, you will be given the option for a live case planning consult.

Order Requirements

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)
Valid email address – If you have selected to received emailed images of plan for approval

Surgical Guides Order

nSequence^® CT Surgical Guides RX Order Form

Patient Information

Bill to Doctor Details

Ship to Doctor Details

Restorative Clinician Details

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

Agreement and Disclosure*

Order Requirements

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

Surgical Guides Order

nSequence® CT Surgical Guides RX Order Form

Patient Information

Bill to Doctor Details

Ship to Doctor Details

Restorative Clinician Details

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

Agreement and Disclosure*

Order Requirements

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

nSequence^® CT Surgical Guides RX Order Form

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