Guided Prosthetics Demo Kit using RX Order form

Doctor Name:*

Facility Name:*

Please be specific if multiple locations exist.

Email:*

Phone:*

Address:

If you are an existing customer, you can skip this.

Order Information

Case Selection:*

Patient Specific Case (Please note below.)
Generic Maxillary Case
Generic Mandibular Case

Demo Kit Purpose (Please select any applicable.):*

Case presentation to patients
Internal staff education
Hands-on course
Tradeshow display

Preferred articulator to be used (Articulator not included. Please select any applicable.):*

Sam III
Panadent
Artex (note: there are two types of Artex, one requiring an extra spacer. Please make sure you indicate in the notes which to be used)
No preference

Choose Implant System:*

Additional Treatment Plan / Notes:

Enter Security Code:

Guided Prosthetics^® Demo Kit Order

nSequence^® Guided Prosthetics Demo Kit RX Order Form

Order Information

Guided Prosthetics® Demo Kit Order

nSequence® Guided Prosthetics Demo Kit RX Order Form

Order Information

Guided Prosthetics^® Demo Kit Order

nSequence^® Guided Prosthetics Demo Kit RX Order Form