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 Wait for ultrasonic

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 - £65 45 Min Hygiene Appointment - £90 Emergency Appointment - £65 Recall/Routine Appointment - £65 Custom Amount

Payment amount

30 Min Hygiene Appointment - £65 45 Min Hygiene Appointment - £90 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

BACS Details

Gentle Dental Care Group

Sort Code: 20-70-15

Account Number: 33511332

Please use your surname as the payment reference

New patient payment amount

30 Min Hygiene Appointment - £65 Emergency Appointment - £75 New Patient Assessment - £75

New patient payment amount

45 Min Hygiene Appointment - £90 Emergency Appointment Deposit - £75 New Patient Assessment - £75 Custom Amount

Custom amount

GDP

Number

Would you like to pay by BACS or card?

BACS Card

BACS Details

Gentle Dental Care Group

Sort Code: 20-70-15

Account Number: 33511332

Please use your surname as the payment reference.

Practice attending *

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

Total

Total to pay *

GBP This amount cannot be edited

Hidden Total

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