Scan Review Order

nSequence^® Scan Review RX Order Form

In order to meet the needs of our clients, we are now offering three levels of Scan Review: CBCT Scan Check, Quick Case Review and Full Case Review.
While we will provide our best evaluation for case efficacy, this laboratory review is not a definitive qualifier or disqualifier for a case. The initial evaluation must be supplemented with a thorough clinical assessment, using complete and accurate records.

For more detailed instructions for scanning of various configurations of dentition, please see:

For more detailed instructions for scanning of various configurations of dentition, please see:

Please submit either of the following.:*

Option 1: CBCT Scan Check ($0)

Once CBCT Scan in DCIOM format is uploaded here, call 888-809-2777 for an immediate review.
RX Submission is not necessary.

Option 2: Quick Case Review ($0)

Assessment of CBCT scan only, to determine if the case is suitable for a full arch, Implant supported restoration. Assessment will be done via email.
*Please upload the following after submission of this form:

CBCT Scan in DICOM format

Option 3: Full Case Review ($300)

Complete workup and implant planning for a full arch Guided Prosthetics case including live consultation with a case planner. This will be credited towards the full arch surgical case if moves to completion.
*Please upload the following after submission of this form:

CBCT Scan in DICOM format
IOS or Impressions/Models
Bite
Photos

Failure to submit necessary records will result in delays to your case.

If mailing your items, please provide tracking number and date of shipment:

Patient Identification

Patient Name:*

Age:*

Gender:*

Billing Doctor Details

The case will be entirely billed to this doctor.

Practice Name:

Organization or Dental Group Name:

NPI/Dental License Number:

Doctor Name:*

Email:*

Phone:*

Address:

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

Treatment Plan Information

Select Arch to Treatment Plan:*

Maxilla
Mandible

Additional Treatment Plan / Notes:*

Please provide as much treatment information as possible so our technicians know what to look for in the CBCT

Note: A tech will reach out via email to begin scan review for option 2 and 3.