Knocklyon Dental Payment Plan

To enable patients to care for their teeth on a regular basis and possibly prevent more expensive courses of treatments such as Root Canal Treatment, Crowns, Bridges and Implants we have introduced a Knocklyon Dental Payment Plan.

Option 1

You agree for us to charge you €20.00 per month to your Credit Card to cover your routine six month examination, cleaning and small x-rays that are required and receive a further 10% discount on all other treatments. This Discount does not apply to Specialists treatments.

Option 2

For agreed Outstanding Accounts, just simply give us your Credit Card details and we will charge an agreed amount monthly to your Credit Card until your account is settled.

We will ask you to sign an agreed contract to this effect to avoid any confusion.

Contract for Payment Plans

Knocklyon Dental Payment Plan Option 1

Patient Name:     

___________________________________

Card Details:

Card Number:

______________________   Expiry Date: _________________ CVV: _______

Agreed Monthly Payment Amount:                           No. of Months:                 

____€20.00_____________________________

Agreed Written Monthly Payment Amount:

______Twenty Euros__________________________________________________________

Agreed date to Charge Credit Card:

_________________________________________________

This is to confirm that I agree to and authorise The Park Clinic Dental to charge to my Credit Card Account, detailed above, the amounts specified above, for my 6 month Examination and cleaning and small x-rays , if necessary, as per Option 1 of The Park Clinic Payment Plan.

Patient Signature:                                                       Dentist Signature:

________________________________                    _____________________________

Nurse Witness Signature:

_________________________________

Dated: ___________________________

Knocklyon  Dental Payment Plan Option 2

Patient Name:     

___________________________________

Card Details:

Card Number:

______________________   Expiry Date: _________________ CVV: _______

Initial Amount Outstanding:

____________________________

Written Amount Outstanding:

________________________________________________________________

Agreed Monthly Payment Amount:                           No. of Months:                     

_________________________________   

Agreed Written Monthly Payment Amount:          

________________________________________________________________

Agreed date to Charge Credit Card:

___________________________________________________

This is to confirm that I agree to and authorise The Park Clinic Dental to charge to my Credit Card Account, detailed above, the amounts specified above, until my account has been paid in full.

Patient Signature:                                                       Dentist Signature:

________________________________                    _____________________________

Nurse Witness Signature:

_________________________________               Dated: ______________________________