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PATIENT REPORT ORDER FORM



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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