0281248953 info@caredentalcasula.com.au

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Payment Plan Application

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Patient Name *

Date *

Parent /Guardian Name *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Treatment and Payment Details

Treatment plan *

Total amount to be paid *

Upfront amount *

Balance *

Frequency of Payments *

Number of installments *

Amount per installment *

Start Date *

End Date *

Comments

Authorize *

I hereby authorize Liverpool Dental Care to charge my card according to the agreed upon payment plan

I hereby agree to the above mentioned treatment and payment plan and authorize Liverpool Dental Care to claim through my card details as agreed above. I have read and understand the Terms and Conditions outlining refund policy and privacy policy.

Dr Amtul Saba
7 De Meyrick Ave, Casula NSW 2170
Ph: 02 8124 8953
E: info@caredentalcasula.com.au
https://caredentalcasula.com.au/

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