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Billing name:††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Tel. no:

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Fax no:

Billing address:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††
††††††††††††††††††††††††††††††††††††††††††††††††††††††††† †††††††††††††††††††††††††††††††††††E-Mail:

Patient Last Name:††††††††††††††††††††††††††††††††††††††††† †††††††† Patient First Name:††††††††††††††††††††††††††††††††

Please circle:†† ††Sex:†† ForM††††††††††† Caucasian~African American~Hispanic~Asian

Birth date:††††††††††††††††††††††††††††††††††† ††††Record date:†††††††††††††††††††††††††††††††††††††††† Record no:

Schedule of charges:†† Maturational report( $48.00 )†† Duplicate copies( $20.00)
†††††††††††† notes: ~there is no additional charge for the optional cephalometric growth estimations
††††††††††††††††††††††† ~ educational institution discounts and customized reports are available

Billing method:††VISA†††††††††† MasterCard†††††††††††† Check enclosed††††††††††††† To be billed†††††††

†††† Card no:††††††††††††††††††††††††††††† ††††††††††††††††††††††††††† expiration date:††††††

††† Signature:

Please return this completed form together with the patientís hand-wristx-ray
†††† and a cephalometric x-ray (optional) to:

GrowthTek~2625 E. Lake Rd.~Skaneateles, NY13152-9012†††† USA

Tel. and Fax: (315)685-6825††††† E-Mail: GrowthTek@AOL.com††††† www.GrowthTek.com

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