PAYMENT PLAN APPLICATION

QTTC Payment Plan Application

If you would like a payment plan please complete the details in this form. Once it has been approved you will be emailed a form for you to complete and bring to your appointment. At the appointment you are required to make the first payment. Payment Plan is available for 6 weekly payments, or 3 fortnightly payments.

PATIENT DETAILS

Please enter the date you have completed the Payment Plan application.
MM slash DD slash YYYY
Patient Name (must match Medicare)(Required)
MM slash DD slash YYYY
Parent (A) Name (must match Medicare)(Required)
Parent (B) Name (must match Medicare)
MM slash DD slash YYYY
MM slash DD slash YYYY
Patient Residential Address(Required)

APPOINTMENT DETAILS

Has an appointment been booked?(Required)
If NO do you want to book an appointment?(Required)
Preferred Location(Required)
Preferred Appointment Time(Required)

MEDICARE DETAILS

Enter all 10 numbers
Please enter a number from 10 to 10.
The number to the left of the patient’s name.
Please enter a number from 1 to 9.
MM slash DD slash YYYY
MM slash DD slash YYYY
The number to the left of the patient’s name.
Please enter a number from 1 to 9.
MM slash DD slash YYYY

PAYMENT PLAN DETAILS

Procedure Required(Required)
Please select the procedure this payment plan applies.
Payment Plan Duration(Required)
Please select the procedure this payment plan applies to.
Payment Plan Terms & Conditions(Required)
Please ensure you read and understand your obligations for a Payment Plan.If you do not agree with any of the terms we recommend you cancel your application.
This field is for validation purposes and should be left unchanged.
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