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NDX nSequence Restorative Rx FORM
NDX nSequence Restorative Rx
Doctor Info
Practice Name
*
Organization or Dental Group Name (if applicable)
*
Doctor Type
*
Select Type of Doctor*
Oral Surgeon
Periodontist
General Dentist
Prosthodontist
Other
NPI/Dental License Number
*
Doctor First Name
*
Doctor Last Name
*
Email Address
*
Office Phone Number
*
Doctor Cell Phone
*
Bill to Doctor Address
*
Select State
*
Select State
Bill to Doctor Zip code
*
Bill to Doctor City
*
Ship to Doctor Details
Is the shipping address same as the billing address?
*
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Ship to Doctor Name
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Ship to Doctor Address
*
Ship to Doctor City
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Select State
*
Select State
Ship To Zip Code
*
Patient Info
First Name
*
Last Name
*
Age
*
Sex
*
Select
Male
Female
PROSTHETIC STAGE
*
Try-in
Select Arch:
Maxilla
Mandible
What type of workflow will you be using
*
Digital Workflow
Digital Workflow Options
*
Finished Try-in (wearable)
Tooth Shade
*
Gingiva Shade
*
Would you like to request changes from the Try-in or Long Term Provisional (LTP)?
*
Yes
No
Please select all that apply:
Midline
Lip Support
Central Length
Buccal Corridors
Occlusal Table
Unfinished Try-in (no pink-not wearable)
Tooth Shade
*
Would you like to request changes from the Try-in or Long Term Provisional (LTP)?
*
Yes
No
Please select all that apply:
Midline
Lip Support
Central Length
Buccal Corridors
Occlusal Table
Analog Workflow
Analog Workflow Options
Soft Tissue Model
Implant Verification Jig
Bite Rim with Two Temp Cylinders
Finished Try-in (wearable)
Tooth Shade
*
Gingiva Shade
*
Would you like to request changes from the Try-in or Long Term Provisional (LTP)?
*
Yes
No
Please select all that apply:
Midline
Lip Support
Central Length
Buccal Corridors
Occlusal Table
Unfinished Try-in (no pink-not wearable)
Tooth Shade
*
Would you like to request changes from the Try-in or Long Term Provisional (LTP)?
*
Yes
No
Please select all that apply:
Midline
Lip Support
Central Length
Buccal Corridors
Occlusal Table
Definitive Prosthesis
Select Arch:
*
Maxilla
Please select the material desired:
*
Zirconia (Monolithic)
Zirconia Over Universal Titanium Bar
Zirconia Over OEM Titanium Bar
NobelProcera Zirconia
Nano Ceramic
Thimble Design Titanium Bar
Individual Zirconia Crowns
Individual Lithium Disilicate Crown
Thimble Design Trilor Bar
Individual Zirconia Crowns
Individual Lithium Disilicate Crown
Mandible
Please select the material desired:
*
Zirconia (Monolithic)
Zirconia Over Universal Titanium Bar
Zirconia Over OEM Titanium Bar
NobelProcera Zirconia
Nano Ceramic
Thimble Design Titanium Bar
Individual Zirconia Crowns
Individual Lithium Disilicate Crown
Thimble Design Trilor Bar
Individual Zirconia Crowns
Individual Lithium Disilicate Crown
Tooth Shade
*
Gingiva Shade
*
Would you like to request changes from the Try-in or Long Term Provisional (LTP)?
*
Yes
No
Please select all that apply:
Midline
Lip Support
Central Length
Buccal Corridors
Occlusal Table
Is Conversion Occlusion dialed in?
*
Select
Yes
No
Notes
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