FINANCIAL AGREEMENT REQUEST

We offer in-house payment agreements, which allow you to spread the cost of your upcoming appointment over up to four (4) payments, with no extra fees. Each payment is due prior to 12pm on the due date.

Please complete this form, and our administration team will reach out to you to discuss further.

Patient full name

Patient date of birth

Day

Month

Year

Name of the person who will be responsible for this payment agreement

Respond N/A if the patient and responsible party are the same person

Email

Phone

Date of your appointment

Date of first payment

Your first payment can be any time prior to your appointment or up to 7 days after the date of your appointment

Preferred payment schedule

Weekly

Fortnightly

Monthly

Preferred contact method

Phone

Email

Payment Plan Request Form

FINANCIAL AGREEMENT REQUEST

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