nSequence® Scan Review RX Order Form

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

Important Information to Review:

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 0.3 voxel is recommended. The smaller the number, the better (ex: 0.2, 0.1, etc.).
  • Scan format: Please send all files in DICOM format.


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


Patient Identification


Billing Doctor Details

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

Treatment Plan Information


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 review the scan.