Surgical Guides Order

nSequence^® CT Surgical Guides RX Order Form

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

Patient Information

Patient Name*

Age

Gender*: Gender* Male Female

Is this a University or Hospital?*: Is this a University or Hospital?* Yes No

Bill to Doctor Details

Practice Name

Organization or Dental Group Name (if applicable)

Doctor Type*

NPI/Dental License Number*

Doctor Name*

Email Address*

Office Phone Number*

Office Cell Phone

Bill to Doctor Address*

Bill to Doctor State*

Bill to Doctor Zip code*

Bill to Doctor City*

Ship to Doctor Details

Is the shipping address same as the billing address? *: Is the shipping address same as the billing address? * Yes No

Restorative Clinician Details

Who is the restorative doctor for this case?*: Who is the restorative doctor for this case?* I am the restorative doctor I am the surgeon working with a different restorative doctor

Who is authorized to approve the surgical plan and manufacturing?*: Who is authorized to approve the surgical plan and manufacturing?* Bill To Doctor Only Restorative Doctor Only Any Doctor listed on RX

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

What NDX lab partner would you like to use for the Digital Workflow?

Would you like to have Chairside Assistance (extra fee applies)?*

Yes - Single Arch $1,000 Yes - Double Arch $1,500 No NOTE: 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 our system. Chairside assistance is dependent upon availability once the case plan has been approved by the clinician.

Please select which bite we should use*: Please select which bite we should use* Physical bite sent Bite from IOS Bite from CBCT

Select one of the following provisional shades. If shade is not listed, please select closest shade. Exact shade match will be done at the final stage*: Select one of the following provisional shades. If shade is not listed, please select closest shade. Exact shade match will be done at the final stage* A1 A2 A3 A3.5 A4 B1 B2 B3 B4 BL1 C1 C2 C3 C4 D2 D3 D4

Gingival Shade*: Gingival Shade* Standard Pink "Dark Vein"

What type of implants are you planning on using?*

What guided surgical instrumentation will you use?*

Preferred Articulator*

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

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

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

Yes Yes, please rush (+$50) 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 to review and approve your case plan?: How would you like to review and approve your case plan? Please email images of my plan for approval. I would like a live consultation with a case planner.

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 Date of surgery is ultimately dependent upon complete record receipt and doctor approval of plan. Your surgery date will be confirmed by our office.

NOTE: Please do not schedule your patient until your ship date has been confirmed with our office.

Desired implant location(s)*

Additional Treatment Plan / Notes:

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 if I choose to cancel the case after the digital planning has been completed, there will be a $100/per arch non-refundable fee for surgical guides with 1-3 implant sites or a $275/per arch non-refundable fee for surgical guides with 4-8 implant sites charged to my account. 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 will be charged if I choose to cancel the case once the digital planning is complete and production begins. I agree that if the nSequence case is approved for a rush fee, there will be a fee of 33.3% of the surgical guide cost applied to the order. If applicable, I understand if clinical photos and shade information are not provided, my case may be delayed. Should your case require a bone foundation guide, you will be given the option for a live case planning consult.

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 following nSequence Records 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)

Liability Acknowledgement*: Liability Acknowledgement* I have read and agree to the Clinical Responsibility and Liability Acknowledgement.

CLINICAL RESPONSIBILITY AND LIABILITY ACKNOWLEDGEMENT

By checking this box, Clinician acknowledges and agrees that Clinician is solely responsible for all clinical decisions and treatment, including diagnosis, treatment planning, implant positioning, surgical execution, prosthetic outcomes, and verification of fit, accuracy, and suitability of any guides, prosthetics, components, treatment plans, or other products or services provided by NDX. All products and services are based solely upon information, scans, impressions, prescriptions, bite registrations, digital files, and approvals provided by Clinician, and NDX does not independently verify the accuracy, completeness, or clinical appropriateness of such information. NDX is acting solely as a dental laboratory and is not engaged in the practice of dentistry or the provision of clinical care.

Clinician acknowledges that guided surgery, implant procedures, digital workflows, and related products involve inherent clinical and manufacturing risks, including but not limited to deviations in fit, implant placement, anatomical variation, software limitations, manufacturing tolerances, component complications, patient-specific conditions, and surgical variables. Clinician assumes all responsibility for evaluating and determining the appropriateness of any product or treatment for each patient and agrees not to rely solely upon any design, guide, recommendation, or output provided by NDX. Clinician further represents that they are properly trained, licensed, and qualified to perform all applicable procedures. Clinician acknowledges that all devices and products are prescription devices intended for use only under the supervision of a licensed dental professional. Any modification, adjustment, misuse, improper storage, resterilization, or unauthorized alteration of any product after delivery shall void any responsibility of NDX relating to such product.

Except as otherwise expressly required by applicable law, ALL PRODUCTS AND SERVICES ARE PROVIDED "AS IS" WITHOUT WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, DESIGN ACCURACY, OR CLINICAL OUTCOME. To the fullest extent permitted by law, Clinician agrees to defend, indemnify, and hold harmless NDX from any claims, liabilities, damages, losses, costs, or expenses, including attorneys' fees, arising from or relating to patient treatment, clinical decisions, surgical procedures, use or misuse of any product, or patient outcomes. NDX's total liability, if any, shall not exceed the amount paid for the specific product or service at issue, and NDX shall not be liable for indirect, consequential, punitive, or patient-related damages.

By checking this box and submitting this prescription, Clinician acknowledges that they have read, understood, and agreed to this Agreement.

Electronic acknowledgement shall have the same force and effect as an original signature.