Park Clinic 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 Park Clinic 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.
Option 3 (Hygiene Plan)
For an agreed amount of €12.50 per month to be charged to your Credit Card, you will receive 1 half hour visit every 6 months with our hygienist. Any extra visits will be discounted by 10% if required.
We will ask you to sign an agreed contract to this effect to avoid any confusion.
Contract for Payment Plans
Park Clinic 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 Credt 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: ___________________________
Park Clinic 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: ___________________________
Park Clinic Dental Payment Plan Option 3
Patient Name:
___________________________________
Card Details:
Card Number:
______________________ Expiry Date: _________________ CVV: _______
Agreed Monthly Payment Amount: No. of Months:
___€12.50______________________________
Agreed Written Monthly Payment Amount:
___Twelve Euros and Fifty Cents_________________________________________________
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 1 half hour visit every six months to the hygienist and receive 10% discount on any extra visits if required with the hygienist.
Patient Signature: Dentist Signature:
________________________________ _____________________________
Nurse Witness Signature:
_________________________________ Dated: ___________________________
