Credit Card details

please provide credit card details below if requested by our staff

I do not have complete private health fund cover and
therefore supply my credit card details below to cover the fees for my procedure.
I have been provided with a fee schedule

Patient Name

First Name

Last Name

Cardholder name

if different

First Name

Last Name

Cardholder Email

Amount

$

Credit Card type

Visa or Mastercard

Credit Card Number

Credit Card Expiry Date

Credit Card CSV number

Message

if requried

A receipt will be provided to allow you to claim a rebate from Medicare