subject_line
Prepayment for Dr Cameron Scott surgical fees
Patient Surname
*
Patient Given Name
*
Street Address
*
Payee Surname
*
Address Line 2
City
*
State
*
NT
ACT
Victoria
Queensland
Tasmania
Western Australia
South Australia
New South Wales
-
-
Post Code
*
Phone Number
*
Email Address
*
Date of surgery
*
+
Payment type
*
Credit Card
Bank Transfer
Credit Card and Direct Deposit Information
Your prepayment details are recieved by TMG as a text document and manually transmitted via our EFT device by COB the following business day.
Name on Card
*
Credit Card Type
*
Visa
MasterCard
Credit Card Number
*
Expiration Date (mm/yy)
*
Amount to be debited from your card and held as deposit for prepayment?
*
THE FEE PAYABLE IS THE AMOUNT STATED ON YOUR FEE ESTIMATE ISSUED BY DR CAMERON SCOTT AT YOUR PRE-OP CONSULTATION. IF THIS AMOUNT VARIES POST SURGERY YOU WILL BE REIMBURSED THE DIFFERENCE
To pay for your surgical fees via Direct Deposit or bank transfer please transfer to:
Dimitri Andropov
Commonwealth Bank:
BSB:
065 -901
Account:
11070899
Reference:
your last name
Territory Medical Group account is held in the name of Dr Dimitri Andropov and distributed to Dr Cameron Scott via an accounting system.