Complete the application form and your plan will become active at
Dental on Beams.
1. Confirm your Dental Care Plan
Select your plan*
Care Plan -ly
Payments
|
- |
Adults |
- |
- |
Children |
- |
-ly
total*
|
$- |
Each Care Plan patient receives:
- 2 x Dental examinations
- 2 x Hygiene treatments including scale and clean
- 2 x Fluoride treatments
- 2 x Dental x-rays
*Each Care Plan incurs a one-off set up fee of
$58.00
payable on activation of plan
2. Enter your details
Additional family members details
Please add names of additional family members receiving treatment
3. Enter your payment details
Note: all credit/debit card transactions will incur a 1.9% surcharge.
4. Confirm your plan details
Please confirm details are correct. Scroll up this form to correct any details.
ly payment plan details
-
There will be ly payments of
$0.00
-
The first payment will be debited from your credit card today.
-
All future payments will be debited to your credit card on the
same weekday as the first payment.
-
All future payments will be debited to your credit card on the
of each
Set up fee
Each Care Plan incurs a one-off set up fee of
$58.00
payable on activation of plan
-
A set up fee totalling
will be debited today.
Patient details
-
Plan type:
Individual
Plan
-
Name:
n/a
-
Date of Birth:
n/a
-
Postcode:
n/a
-
Phone number:
n/a
-
Email:
n/a
Direct-debit details