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

Select how you would like to have your case approved:*

Please email images for case approval (valid email required).
I would like to approve my case with a live consult session.

Ship case to this address:*

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

In order to complete this case, I have provided nSequence with the following:*

This complete RX with all information and thorough instructions
Clinical digital photos of patient with shade tab (if nSequence is to make the provisional restoration)
Upper and lower conventional VPS impressions or poured models sent via mail or local pickup
Blu-Mousse bite in MIP using nSequence protocol via mail or local pickup
STL digital impressions
Patient scan in DICOM format (upload after submission of this form)
Denture scan in DICOM format (upload after submission of this form)
Patient scan in DICOM format (will be sent on CDs)
Denture scan DICOM format (will be sent on CDs)

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

Patient Identification

Patient Name:*

Age:

Gender:*

Referring Information

Were you referred by an NDX lab?:*

Yes
No

Were you referred by an implant or lab representative?:*

Yes
No

Treatment Planning Details

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

Please include the following people in the planning session:*

Bill to Doctor Details

The case will be entirely billed to this doctor.

Practice or Organization Name (if applicable):

Doctor Name:*

NPI/Dental License Number:*

Email Address:*

Confirm Email:*

Office Phone Number:*

Cell Phone Number:

Address:

Supporting Clinician Details

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

Practice or Organization Name (if applicable):

NPI/Dental License Number:

Supporting Doctor Name:

Email Address:

Office Phone Number:

Cell Phone Number:

Address:

Treatment Plan Information

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

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

Maxilla
Mandible
No

Would you like us to add an anatomical model to your order? (added cost per arch):*

Yes
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.

Desired implant location(s):*

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.

Additional Treatment Plan / Notes:

Case processing agreement and disclosure*

By checking this box, I certify that the patient is financially committed to this treatment plan.

By checking this box, I agree that if I choose to cancel the case once consultation has been scheduled, there will be a $100.00/per arch non-refundable deposit for surgical guides with 1-3 implant sites or $275.00/per arch non-refundable deposit for surgical guides with 4-8 implant sites charged to my account. If the case is reinstated within 90 days from cancelation, the deposit can be reapplied toward the total cost of the case.

By checking this box, I am aware that the total case cost will be charged if I choose to cancel the case once consultation is complete and production begins.

I understand if clinical photos and shade info are not provided on or before consultation, my case may be delayed.

By checking this box, 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.

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.