nSequence | CT Surgical Guides RX Order Form

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

Patient Information

Gender:*

MaleFemale

Bill to Doctor Details

Supporting Clinician Details

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

Select arch to treatment plan:*

Maxilla
Mandible

What type of implants are you planning on using?:*

What guided surgical instrumentation will you use?:*

Preferred articulator:*

Are you planning on sinus lifts/augmentation?:*

Yes
No

Are you planning on bone grafting?:*

Yes
No

Are you planning on extractions?:*

Yes
No

Is nSequence fabricating the provisional(s)?:*

Yes
No

Are you sending in upper and lower conventional VPS impressions/models OR STL digital impressions? Please check one:*

Conventional VPS impressions/models
STL digital impressions

Would you like us to make a temporary backup denture (+$325/arch)?:*

Maxilla
Mandible
No

Would you like to add a Radiology Report to your order and have the scan interpreted by a radiologist (+$125)?:*

Yes
Yes, please rush (+$35)
No

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.

How would you like your surgical report delivered?:*

Print
Digital
Both

Desired implant location(s):*

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

Additional Treatment Plan / Notes:

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

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

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 – You will receive emailed images of your case plan for approval.

Tracking Information:If you are mailing case records to the nSequence lab, please indicate your tracking number and date of shipment below:

Ship To Address:

Surgical Guides Order

nSequence^® CT Surgical Guides RX Order Form

Patient Information

Bill to Doctor Details

Supporting 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 $275 and includes all of the following:

Surgical Guides Order

nSequence® CT Surgical Guides RX Order Form

Patient Information

Bill to Doctor Details

Supporting 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 $275 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