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Surgical Guides Order
n
Sequence
®
CT Surgical Guides RX Order Form
1
2
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PATIENT AND DOCTOR INFORMATION
All fields indicated by * or in red are required.
Patient Information
Patient Name*
Age
Gender*:
Gender*
Male
Female
Is this a University or Hospital?*:
Is this a University or Hospital?*
Yes
No
Bill to Doctor Details
Practice Name
Organization or Dental Group Name (if applicable)
Doctor Type*
Select Type of Doctor*
General Dentist
Oral Surgeon
Periodontist
Prosthodontist
Resident
Other
NPI/Dental License Number
Doctor Name*
Email Address*
Office Phone Number*
Office Cell Phone*
Bill to Doctor Address*
State*
Select State*
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
QC
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Bill to Doctor Zip code*
Bill to Doctor City*
Ship to Doctor Details
Is the shipping address same as the billing address? *:
Is the shipping address same as the billing address? *
Yes
No
Restorative Clinician Details
Who is the restorative doctor for this case?*:
Who is the restorative doctor for this case?*
I am the restorative doctor
I am the surgeon working with a different restorative doctor
TREATMENT PLAN
All fields indicated by * or in red are required.
Treatment Planning Details
Select arch to treatment plan*:
Select arch to treatment plan*
Maxilla
Mandible
What NDX lab partner would you like to use for the Digital Workflow?
Dynamic Dental Solutions (Default)-Jacksonville, FL
NDX Green-Heber Springs, AR
NDX Mallow-Tru-Lee’s Summit, MO
NDX Twin Cities-Falcon Heights, MN
Would you like to have Chairside Assistance (extra fee applies)?*
Yes - Single Arch $1,000
Yes - Double Arch $1,500
No
NOTE:
nSequence highly recommends chairside assistance for 1st time users to ensure ease of delivery. Our technicians are comprehensively trained on the best way to proceed with our system. Chairside assistance is dependent upon availability once the case plan has been approved by the clinician.
Please Select which bite we should use*:
Please Select which bite we should use*
Physical bite sent
Bite from IOS
Bite from CBCT
Select one of the following provisional shades. If shade is not listed, please select closest shade. Exact shade match will be done at the final stage*:
Select one of the following provisional shades. If shade is not listed, please select closest shade. Exact shade match will be done at the final stage*
A1
A2
A3
A3.5
A4
B1
B2
B3
B4
BL1
C1
C2
C3
C4
D2
D3
D4
Gingival Shade*:
Gingival Shade*
Standard Pink
"Dark Vein"
What type of implants are you planning on using?*
What guided surgical instrumentation will you use?*
Preferred Articulator*
Choose one
Stratos (nSequence Default)
Artex
Denar 320
Denar Magnetic
Denar Regular
Kavo
Panadent
SAM 3
My articulator is not listed. Please use nSequence Default
Are you planning on extractions?*:
Are you planning on extractions?*
Yes
No
Are you sending in upper and lower conventional VPS impressions/models OR STL digital impressions?*:
Are you sending in upper and lower conventional VPS impressions/models OR STL digital impressions?*
Conventional VPS impressions/models
STL digital impressions
Would you like to add a Radiology Report to your order and have the scan interpreted by a radiologist (+$125)?*
Yes
Yes, please rush (+$50)
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 to review and approve your case plan?*:
How would you like to review and approve your case plan?*
Please email images of my plan for approval.
I would like a live consultation with a case planner.
How would you like your surgical report delivered?*:
How would you like your surgical report delivered?*
Print
Digital
Both
Do you have a proposed surgery date?*
Yes
No
Date of surgery is ultimately dependent upon complete record receipt and doctor approval of plan. Your surgery date will be confirmed by our office.
NOTE:
Please do not schedule your patient until your ship date has been confirmed with our office.
Desired implant location(s)*
Additional Treatment Plan / Notes:
CASE PROCESSING
All fields indicated by * or in red are required.
Agreement and Disclosure*
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*:
Order Requirements*
In order to complete this case, I have provided nSequence with the following:*
Order Requirement List
Clinical digital photos of patient
Upper and lower conventional VPS impressions/poured models OR STL digital impressions
Blu-Mousse® bite following nSequence Records 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)
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