Guided Prosthetics Order

nSequence^® Guided Prosthetics^® RX Order Form

ORDER AND SHIPPING INFORMATION
All fields indicated by * or in red are required.

NOTE: Promo codes cannot be applied in conjunction with any other offers or discounted pricing.

Approval and Shipping Details

Select how you would like to have your case approved:*: Please email images for case approval (valid email required). I would like to approve my case with a live consult session.

IMPORTANT: Make sure this is correct. nSequence will not be held responsible for incorrectly inputted address.
NOTE : Please do not schedule your patient until your ship date have been confirmed with our office.

CASE PROCESSING
All fields indicated by * or in red are required.

Agreement and Disclosure*

Agreement Disclosure*: By checking this box, I certify that the patient is financially committed to this treatment plan. I agree that bundled cases (includes the final restoration) are non-refundable and must be redeemed within 9 months from the day of surgery. I agree that if I choose to cancel the case, once the consultation has been scheduled, there will be a $300/per arch non-refundable fee for the nSequence Guided Prosthetics case. If the case is reinstated within 90 days from cancelation, the fee can be reapplied toward the total cost of the case. I am aware that the total case cost of the nSequence Guided Prosthetic will be charged if I choose to cancel the case once the consultation is complete and production begins. I understand if clinical photos and shade information are not provided on or before the consultation, my case may be delayed. I agree that if the nSequence case is approved for a rush fee, there will be a $1,250/per arch charge for the nSequence Guided Prosthetics case.

Order Requirements

Order Requirements*: In order to complete this case, I have provided nSequence with the following:*

Clinical digital photos of patient
Upper and lower conventional VPS impressions/poured models OR STL digital impressions
Blu-Mousse® bite in MIP using nSequence protocol
Patient scan in DICOM format (upload after submission of this form or sent on CDs)
Denture scan in DICOM format (upload after submission of this form or sent on CDs)

If you are mailing case records to the nSequence lab, please indicate your tracking number and date of shipment below:

The cost of the nSequence Guided Prosthetics Kit is $3,300 and includes all of the following:

Collaborative Surgical Planning
Anatomical Model
Bone Foundation Guide (Reduction Guide)
Surgical Guide
Start Bite, Angle Rotation/Bone Cut Verification Guide
Tissue Gasket
2 Lucitone^® Long Term Provisionals
Surgical Report

Guided Prosthetics Order

nSequence^® Guided Prosthetics^® RX Order Form

Patient Information

Bill to Doctor Details

Restorative Clinician Details

TREATMENT PLAN
All fields indicated by * or in red are required.
Treatment Planning Details

Approval and Shipping Details

Agreement and Disclosure*

Order Requirements

The cost of the nSequence Guided Prosthetics Kit is $3,300 and includes all of the following:

Guided Prosthetics Order

nSequence® Guided Prosthetics® RX Order Form

Patient Information

Bill to Doctor Details

Restorative Clinician Details

TREATMENT PLAN All fields indicated by * or in red are required. Treatment Planning Details

Approval and Shipping Details

Agreement and Disclosure*

Order Requirements

The cost of the nSequence Guided Prosthetics Kit is $3,300 and includes all of the following:

nSequence^® Guided Prosthetics^® RX Order Form

TREATMENT PLAN
All fields indicated by * or in red are required.
Treatment Planning Details