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:


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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

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.

 

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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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.