Financial Consent and Payment for Medical Assessment

Thank you. A booking has been received for medical assessment and will be confirmed upon receipt of payment

Candidate's details

Candidates surname *

Candidates given name *

Date of medical assessment booking * +

Time of medical assessment booking *

Urine Drug Screen Financial Consent

If the requested medical involves an instant drug urine screen, a lab confirmation test for a non neg result will be an option. ? An additional fee of $99.00 will be charged directly from the Pathology provider. To ensure timely return of medical assessment results please ensure you select appropriately. Do you consent to a non neg lab confirmation *

Details of financial consent and payment

Name of company and person responsible for payment if candidate please type self *

Email address of client whom is responsible for financial consent

Email address to send tax invoice and medical *

Signature of client whom is responsible for financial consent *

clear

Payment by Card /or direct deposit

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Practitioners have appointed TMG to invoice and collect all services payable for practitioner services associated with this medical assesment.

To pay via bank via direct deposit or bank transfer

Dr Dimitri Andropov

Commonwealth Bank

BSB: 065 - 901

Account: 11070899

Reference: Candidates name

How your payment is received and receipted

Your payment details are received by TMG as a text document and manually transmitted by our EFT device by COB the following day.

A detailed invoice and receipt will be issued for accounting and taxation purposes to the email address which you have nominated.