ORDER

TO OBTAIN YOUR PERSONAL VIDEO AND WRITTEN TREATMENT PLAN

PLEASE FOLLOW THESE INSTRUCTIONS

Step1

Please make a note of our address and phone number as you will need to give this to your medical practitioner.

Suite 205 7 Help Street Chatswood 2067

Phone: (02) 9411 5116

Step 2
Visit your medical practitioner and get a referral to your local radiologist for the following radiographs which need to be posted to our address.

Orthopantomogram (OPG) and CT scans of your jaws

Step 3

Please complete the form below to provide me with your name, date of birth, phone number, email address, any medical conditions you may have and

any medications you may be taking regularly.

Step 4

Please mail your radiographs and completed form to our clinic where I shall analyse your information and contact you by email as soon as possible

with a link to the video presentation of your treatment plan. Please allow two weeks for delivery.

The current fee for this service is $AUD750.00 which is payable once you submit the form below.

If you choose to send your radiographs first, we shall request that you complete this form and make your payment before the analysis can be carried out.

Please note that the cost of this service will be credited to your treatment, should you decide to proceed with my recommendations within 3 months.

This credit will be applied for treatment provided in our clinic only and is not transferable to any other practice.

1. PLEASE COMPLETE THE FORM BELOW

2. CLICK THE SUBMIT BUTTON AND MAKE YOUR PAYMENT SECURELY THROUGH PAYPAL

3. POST YOUR RADIOGRAPHS TO MY CLINIC AND EXPECT A PHONE/EMAIL CONFIRMATION WITHIN 7 DAYS THAT WE HAVE RECEIVED THEM

4. EXPECT DELIVERY OF YOUR TREATMENT PLAN PRESENTATION WITHIN 14 DAYS.

Please contact Shannon or Jenny on (02) 9411 5116 if you have not received notification of completion within that time.

Your Doctor's Phone Number *

Describe Your Problem And What You Would Ideally Like As A Solution *

Your Full Name: *

Email: *

Date Of Birth *

Past and Present Medical Conditions *

Preferred Phone Number *

Your Doctor's Name *

Your Doctor's Address *

Medications You Take Regularly *

The Australian National Centre For Keyhole Implant Dentistry