By signing this form, you ackowledge that you have read and agree to the terms of trade hereafter. Please download New Patient Questionaire, Complete and email to reception@silverstreammedicalcentre.co.nz
Terms of Trade
The following Terms of Trade apply to services provided by Silverstream Medical Centre to its patients.
By Signing, you hereby agree to the Terms and Conditions of Trade as stated
1. Our fees are available upon request. These charges take into account the following factors:
a. The time spent
b. The complexity of treatment
c. The costs of running a medical practice
d. The funding available from the government, public agencies and other sources.
2. Unless by prior arrangement, all services shall be paid on the date of the service.
3. We would be very concerned if any patient deferred seeking medical help due to the cost. If this is the case, please, talk to your doctor or the practice manager so other payment options can be arranged.
4. Payment shall be accepted by cash, Cheque, Eftpos, Credit Card or automatic payment.
5. Where it is agreed that payment need not be paid on the day of the service, it shall be paid within 7 days of the date of the invoice or by the date agreed with the Doctor or Practice Manager. An account fee of $10 is added to all accounts not paid on the day.
6. Where patients are in breach of agreed payment terms, referral of the debt, including the provision of necessary contact details may be sent to a debt collecting agency. Costs incurred to recover outstanding monies will be charged to the patient. This may result in patient name and address entered into the computer Bureau default listing which will have an impact on patient's credit rating.
7. Variations to the Terms of Trade may occur from time to time and Silverstream Medical Centre will notify the patient by way of invoice - receipt of which shall be deemed acceptance by the patient.
Patient/Representative name: ____________________________________