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

Referring Information

Were you referred by an NDX lab?:*

Yes
No

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

Yes
No

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

Please include the following people in the planning session:*

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 temporary backup 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).

Additional Treatment Plan / Notes:

ORDER AND SHIPPING INFORMATION
All fields indicated by * or in red are required.

Approval and Shipping Details

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.

IMPORTANT: Make sure this is correct. nSequence will not be held responsible for incorrectly inputted address.

NOTE: Please do not schedule your patient until your ship date has been confirmed with our office.

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.

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 fee for surgical guides with 1-3 implant sites or $275.00/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 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.

Order Requirements

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)

Surgical Guides Order

nSequence^® CT Surgical Guides RX Order Form

Patient Information

Bill to Doctor Details

Supporting Clinician Details

Referring Information

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

Treatment Plan Information

Approval and Shipping 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

Referring Information

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

Treatment Plan Information

Approval and Shipping 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