Direct Debit Request

If you would like your direct debit to be paid via credit card, please CLICK HERE to print out our physical direct debit form. Fill this in and return to our team as soon as possible.

All communication addressed to us should include the patient’s name and bill payer’s name. Receipt of payment will be emailed to the address provided below.
Part A – Your Details
Payer's Name*
First Last
Patient's Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Part B – Schedule
All payments will be Direct Debited on the 1st or the 15th of the month, on a monthly basis. Should this date fall on the weekend, they will be processed the next banking day.
Payment Amount $*
Number of Payments*
Day to be Debited*
(please select the date you would like)
Part C – CHEQUE/SAVINGS ACCOUNT or CREDIT CARD AUTHORISATION
I/We request South East Orthodontics to arrange for funds to be debited from*
- My nominated account at the financial institution according to the specified schedule.
- My nominated credit card according to the schedule specified on page 1.
Financial Institution*
Branch*
Account Name*
BSB*
Account Number*
If debiting from a joint bank account, both signatures are required
Signature*
Date*
MM slash DD slash YYYY
Signature
Date
MM slash DD slash YYYY
Download the physical direct debit form.
If you would like your direct debit payment to be made via credit card, please fill out the physical form linked at the top of this page and return to us as soon as possible.

Berwick

Monday

Tuesday

Wednesday

Thursday

Friday

Direct Debit Request

DIRECT DEBIT REQUEST

Part A – Your Details

Part B – Schedule

Part C – CHEQUE/SAVINGS ACCOUNT or CREDIT CARD AUTHORISATION

Download the physical direct debit form.

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