Payment Form.

This payment form is needed for non-eligible children. A discounted payment from $199 to only $79 for a limited time.

YOU CAN TRANSFER $79 to the following account:

NSW DENT

BSB:062223

Account Number: 11639315

School/Day-Care Name

Child Name

First Name

Last Name

Child Date of Birth

Message

Parent/ Guardian Name

First Name

Last Name

I consent for my child to be seen by Dentist/Therapist

Check-up

Clean & polish

Name on the card

First Name

Last Name

Card Number {Only numbers No spaces}

Expiry Date

YYYY

CCV

Phone Number