nSequence® Scan Review RX Order Form

Please complete the entire form below. All fields indicated by * are required. Scans per arch cost $100.  

Before you begin, please review the CT Guided Scan Protocol and Scan Quality tips.  You will also need to have the following in order to process your case:

  • Scan of patient (Required)
  • Scan of denture with markers (Dual Scan Protocol - if applicable; Optional if more detail is needed)
  • Upper and lower impressions or models (Optical Scan Conversion - if applicable; Optional if more detail is needed)

CT Guided Scan Protocol:

Scan Quality:

Before submitting your case, check that all your scans adhere to the following guidelines:
  • Scan field of view: Make sure no part of the desired arch to be treatment planned is cut off, there is no patient movement, and a scan appliance was used.
  • Scan resolution: Minimum of 0.3voxel is recommended. The smaller the number, the better (ex: 0.2, 0.1, etc.).
  • Scan format: Please send all files in DICOM format.

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

 

Patient Identification

 
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Billing Doctor Details

The case will be entirely billed to this doctor.
 
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If you are an existing customer, you can skip this.

Treatment Plan Information

 
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