Procedure Booking Form

Name:                                                                                Date:

            Method of Payment (please circle one)

1.             Direct Credit (BSB: 083155 ACC: 867506071)

2.             Cash

3.             Bank Cheque

4.             Mediplan _________________________

5.             Credit Card

Name:_________________________ 

Card Number: _______________________  

Expiry Date: ____/_____ 

Signature : ____________________________

            Please note:

1. Cheque (Personal)

If full payment is intended by personal cheque, funds for the full amount must be received 7 days prior to procedure date.

2. Cash

Please do not forward cash in the mail. Please call Louise on (03) 9826 6200 prior to attending the office to ensure your cash payment can be collected and receipted properly.

3. Credit Card

A surcharge of 3% applies for Diners Club and Amex.

For all transactions over $500.00, a surcharge of 1% applies to all Visa and Mastercard credit card transactions.