BETWEEN:


    Beyond Smiles Mordialloc Trust trading as Beyond Smiles Dentistry ABN 67 286 931 853 (”the Dentist”)
    and (name*) of (address*) ("the Patient")
    General Terms

    • All account relating to services rendered to be settled in full on the day.
    • A valid and current private health insurance card is required if your HICAPS claim is to be processed on the day, otherwise the full account needs to be settled.

    Other Terms

    • If there is an outstanding account for any treatment, a recognised form of identification of the patient i.e. Drivers license, will be required to be given to the Dentist. An arrangement will be made on a certain day (no more than 7 days) on which the balance of the account will be settled in full.
    • Failure to settle the account as promised will result in interest being charged at the rate of 6% per annum.
    • If the account still remains unpaid, further legal action will be taken. (A minimum processing fee of $150 or 35% whichever is greater will be added to the outstanding account by the Dentist plus any other costs incurred in collecting the debt plus legal costs).
    • The patient acknowledges that in the case of default, by the Patient, the debt will be referred to a bad credit database
    Date
    Patient Signature
    Patient Name