Guided Prosthetics Order

nSequence^® Guided Prosthetics^® RX Order Form

FinalRestoText

OFFERING OEM TITANIUM BARS FOR OUR PREFERRED PARTNERS :

OEM

NOTE: Cases from other implant companies will not be OEM unless customer calls and requests it. Other OEM bar options may result in additional charges

Lock in the definitive restoration price when bundling with the nSequence Guided Prosthetics Kit. To add the definitive, please select one of the following options (bundled cost includes nSequence Guided Prosthetic Kit of $3,300 + definitive restoration). If you do not need the definitive restoration, please select No and you will only be charged the $3300 base fee*: Lock in the definitive restoration price when bundling with the nSequence Guided Prosthetics Kit. To add the definitive, please select one of the following options (bundled cost includes nSequence Guided Prosthetic Kit of $3,300 + definitive restoration). If you do not need the definitive restoration, please select No and you will only be charged the $3300 base fee* Screw-Retained Hybrid Prosthetic Denture Teeth and Acrylic with OEM (original-on-original) Milled Titanium Bar ($6,415*) Screw-Retained Hybrid Monolithic Zirconia (no cutback) ($7,415*) Screw-Retained Hybrid Monolithic Zirconia (anterior cutbacks) ($7,815*) Screw-Retained Hybrid Crystal® Ultra Nano-Ceramic Prosthetic ($7,415*) NobelProcera® Zirconia Implant Bridge ($7,800*) Screw-Retained Hybrid Titanium Copy-Milled Prosthetic with individual solid Zirconia crowns ($8,715*) Screw-Retained Hybrid Titanium Copy-Milled Prosthetic with individual Lithium Disilicate crowns ($9,515*) No final restoration is needed ($3,300)

PATIENT AND DOCTOR INFORMATION
All fields indicated by * or in red are required.

Patient Information

Patient Name

Age

Gender*: Gender* Male Female

Bill to Doctor Details

Practice Name

Organization or Dental Group Name

Doctor Type*

NPI/Dental License Number*

Doctor Name*

Office Phone Number*

Cell Phone Number*

Email Address*

Confirm Email*

Address*

State*

Zip Code*

City*

Restorative Clinician Details

Practice or Organization Name (if applicable):

NPI/Dental License Number:

Restorative Doctor Name

Email Address

Office Phone Number

Cell Phone Number

Address

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

Select arch to treatment plan*: Select arch to treatment plan* Maxilla Mandible

Would you like to have Chairside Assistance (extra fee applies)?*: Would you like to have Chairside Assistance (extra fee applies)?* Yes – Single Arch $1,000 Yes – Double Arch $1,500 No

Chairside Assistance Pop

*nSequence highly recommends chairside assistance for 1st time users to ensure ease of delivery. Our technicians are comprehensively trained on the best way to proceed with the nSequence Guided Prosthetics System. Chairside assistance is dependent upon technician availability once the case plan has been approved by the clinician.

What type of implants are you planning on using?*

Which Implant Manufacturer's fully guided surgical kit will you be using?*

IMPORTANT NOTE: nSequence uses the manufacturer's latest version of their fully guided surgical kits.

Preferred articulator*

Are you changing/increasing the VDO?*: Are you changing/increasing the VDO?* Yes (Please submit an anatomic bite at the designed VDO and jaw relationship) No

Are you planning on sinus lifts/augmentation?*: Are you planning on sinus lifts/augmentation?* Yes No

Are you planning on bone grafting?*: Are you planning on bone grafting?* Yes No

Are you planning on a bone reduction?*: Are you planning on a bone reduction?* Not sure, nSequence can recommend Yes No

Are you planning on extractions?*: Are you planning on extractions?* Yes No

Is nSequence fabricating the provisional(s)?*: Is nSequence fabricating the provisional(s)?* Yes No

Are you sending in upper and lower conventional VPS impressions/models AND/OR STL digital impressions?*: Are you sending in upper and lower conventional VPS impressions/models AND/OR STL digital impressions?* Conventional VPS impressions/models STL digital impressions

Would you like us to make a temporary backup denture (+$325/arch)?*: Would you like us to make a temporary backup denture (+$325/arch)?* Maxilla Mandible No

Would you like to add a Radiology Report to your order and have the scan interpreted by a radiologist (+$125)?*

Yes Yes, please rush (+$35) No NOTE: Standard turnaround time to forward scan to radiologist is 5 to 7 business days and rush cases are completed by the end of the next business day for an additional fee.

How would you like your surgical report delivered?: How would you like your surgical report delivered? Print Digital Both

Do you have a proposed surgery date?*

Yes No NOTE: Date of surgery is ultimately dependent upon complete record receipt, GoToMeeting scheduling and GoToMeeting completion. Please allow 4-6 weeks for surgery scheduling.

Desired implant location(s):*

Additional Treatment Plan / Notes

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

Promo Code

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:*: 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.

Ship nSequence completed case to this address**

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*: 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) will be charged to the credit card at the same time the nSequence Guided Prosthetics Surgical Kit is shipped out. The bundled final restoration is 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*: Order Requirements* In order to complete this case, I have provided nSequence with the following:*

Order Requirement List

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: Tracking Information

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