Payment Form

Start time

DayMonthYear
DateHourMinutesAM/PM Option
Reconciled with SFD?
Which day of the week would you prefer for your appointment?

Any / First AvailableMondayTuesdayWednesdayThursdayFriday
Which time slot would you prefer?

Any / First Available9 - 11 AM11 - 1PM2 - 4 PM4 - 6 PM
Who is making the payment?*

Payment by patientPayment on behalf of patientStaff
Name of staff member*
Patient name*

First NameLast Name
Contact Number*
Date of birth*

DayMonthYear
Email*

Confirmation Email
Email Address*
Address (Start by typing your post code and then complete any missing fields)*
Are you an existing patient of ours?*

YesNo
Payment amount*

30 Min Hygiene Appointment - £8545 Min Hygiene Appointment - £127.50Emergency Appointment - £90Recall/Routine Appointment - £80Custom Amount
Payment amount*

30 Min Hygiene Appointment - £8545 Min Hygiene Appointment - £127.50Emergency Appointment Deposit - £90Recall/Routine Appointment - £80Custom Amount
Custom amount
GBP
Number
Would you like to pay by BACS or card?

BACSCard
New patient payment amount*

30 Min Hygiene Appointment - £85Emergency Appointment - £90 + work requiredNew Patient Assessment - £90Endo / Implant / Perio Consultation - £90
New patient payment amount*

45 Min First Hygiene Appointment - £127.50Emergency Appointment - £90 + work requiredNew Patient Assessment - £90Custom Amount
Custom amount
GDP
Number
Would you like to pay by BACS or card?

BACSCard
Practice attending*

132 Wickham Road391 Wickham Road149 Shirley Road29A Whitehorse RoadPurley Whites, 143 Haling Park Road126 High StreetUnsure
Total
Please ensure you have entered the right amount
Please note we are currently fully booked at 29A until 2023. Please select another practice if your treatment is needed sooner.
Total to pay

prevnext( X )
GBP
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Company registration: GDCG Limited, Company No. 11646605, 132 Wickham Road, Croydon, CR0 8BE
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