FPG_Payment Method Confirmation

Before clients can access some of our services we require that they provide us with a nominated 'Bill Payer'. The Bill Payer is required to confirm with us their preferred payment method to enable us to confirm appointments.

Please complete this if you are:

Self funding your services
The nominated Bill Payer

I am the Bill Payer for:*

MyselfSomeone else

I would like to pay using:*

Automatic Payment MethodPre-Pay Method

Surname name of the individual you are funding?

Referral or Case URN (if known)

This will start REF-XXXX-2018 or CAS-XXXXX-XXXX

Your Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Area CodePhone Number

Automatic Payment Method

As you have chosen to pay using our automatic payment method you will shortly be sent a link from GoCardless/Family Practice Group asking you to authorise a direct debit mandate with us.

This is to enable us to charge your appointments and collect payment. Once authorised you will recieve an invoice on the day of the appointment and payment will be taken automatically (usually 2 to 4 days following).

As a big thank you for choosing this method we will reduce your fees by £5 each time.

You may still cancel without charge by providing us with 24 hours notice during practice opening times.

Pre-Pay Method

As you have chosen to fund services using our pre-pay method we require a credit or debit card to hold on file so that we can charge for your appointments.

Your credit/debit card will be held by Stripe and not ourselves.

Stripe has been audited by a PCI-certified auditor and is certified to PCI Service Provider Level 1. This is the most stringent level of certification available in the payments industry.

Your chosen card will be charged 24 to 48 hours in advance of each appointment.

You may still cancel without charge by providing us with 24 hours notice during practice opening times.

Pre Pay Method(£ Free for each day)

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By providing us with your credit / debit card you acknowledge that your card will be charged 24 to 48 hours prior to any appointments that are confirmed for either you or the individual you are responsible for named above.*

I consent and understand

Please provide your signature below*

Payment Method Confirmation

Your Preferred Payment Method