nSequence® CT Surgical Guides RX Order Form

IMPORTANT: Review disclaimer and other important information before filling and submitting form!
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Patient Information

 

Bill to Doctor Details

 

Ship to Doctor Details

 

Restorative Clinician Details



Treatment Planning Details

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.
Date of surgery is ultimately dependent upon complete record receipt and doctor approval of plan. Your surgery date will be confirmed by our office.
Please do not schedule your patient until your ship date has been confirmed with our office.

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 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)