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Date:
Name of the Doctor

Street and Number                                              

   

City
  State 
 PCode  
Telephone
 Fax

E-mail
 
 
Patient Name
Date of Birth
X ray  

Before During After Treatement
 
Please perform the following:
Bimler analysis       US$ 30.00
Sassouni analysis    US$ 30.00
Ricketts analysis   US$ 30.00
Ricketts superimposition   
(requires before and after ceph. x rays)		 US$ 30.00

Steiner analysis  (+Wits and Tweed)   

 US$ 30.00
Model Analysis  
Pont's
US$ 10.00
Schwarz US$ 10.00
Bolton US$ 10.00
Mixed Dentition US$ 10.00
   

Full report including Diagnosis and Treatment Plan A$200.00

(does not include the fees for the cephalometric or model analysis required)
   

I have sent the following:

 

Panoramic (OPG) x ray

Cephalometric x ray (lateral view)

Photos

Study models and Maxilo / Mandibular bite 

     registration on Centric Relation

Relevant Clinical information

Other  (specify)

 

Please do the report based on the [name(s) of cephalometric analysis]

 

Please send results via     E-mail:      or    Courier

 

 

Note: Delivery charges are not included.

Payment Details:

If you prefer you can print and fax credit card details to +61-2-9724-4993
or post a cheque or money order to.
DR C Gonzalez, 22 Cunninghame Street Fairfield, NSW 2165 Australia 
 
Credit Card Payment:   
Amount
Due:
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Amex
Cardholder's Name:
Card Number:
Expiry Date:

 
Pay by Cheque: