Payment Form

Start time

Date Hour Minutes AM/PM Option

Reconciled with SFD?

Which day of the week would you prefer for your appointment?

Any / First Available Monday Tuesday Wednesday Thursday Friday

Which time slot would you prefer?

Any / First Available 9 - 11 AM 11 - 1PM 2 - 4 PM 4 - 6 PM

Who is making the payment? *

Payment by patient Payment on behalf of patient Staff

Name of staff member *

Patient name *

First Name Last Name

Contact Number *

Date of birth *

Day Month Year

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? *

Yes No

Payment amount *

30 Min Hygiene Appointment - £70 45 Min Hygiene Appointment - £105 Emergency Appointment - £65 Recall/Routine Appointment - £65 Custom Amount

Payment amount *

30 Min Hygiene Appointment - £70 45 Min Hygiene Appointment - £105 Emergency Appointment Deposit - £65 Recall/Routine Appointment - £65 Custom Amount

Custom amount

GDP

Number

Would you like to pay by BACS or card?

BACS Card

New patient payment amount *

30 Min Hygiene Appointment - £70 Emergency Appointment - £80 New Patient Assessment - £80

New patient payment amount *

45 Min Hygiene Appointment - £105 Emergency Appointment Deposit - £75 New Patient Assessment - £80 Custom Amount

Custom amount

GDP

Number

Would you like to pay by BACS or card?

BACS Card

Practice attending *

132 Wickham Road 391 Wickham Road 149 Shirley Road 29A Whitehorse Road Purley Whites, 143 Haling Park Road 126 High Street Unsure

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

GBP

This information is encrypted using industry-standard encryption during transmission with the appropriate banking institution.

Company registration: GDCG Limited, Company No. 11646605, 132 Wickham Road, Croydon, CR0 8BE