Short Street Dental (Southport)

Care Plan treatments	Usual	Care Plan price
2 x Dental examinations	$170.00	12 easy monthly payments of $30.00
2 x Hygiene treatments including scale and clean	$224.00
2 x Fluoride treatments	$86.00
2 x Dental x-rays	$86.00
Your discount		save $206.00
You pay total	$566.00	$360.00

Thank you for your interest in joining the Short Street Dental (Southport) Care Plan

Complete the application form and your plan will become active at Short Street Dental (Southport).

You will recieve an email to confirm your email address is correct.
Please follow the instructions in the email to confirm.

1. Confirm your Dental Care Plan

Select your plan*

Individual

Couple (2 adults)

Family

adults

children

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

First name*

Surname*

Email*

Phone*

Date of Birth*

Postcode*

3. Enter your payment details

Same as your name

First name on card*

Surname on card*

Credit Card Number*

Expiry date*

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

n/a n/aly

I have read and I understand and agree to the terms and conditions governing the debit arrangements between myself and Dental Members Australia Pty Ltd (User ID 415095) as set out in this request.

Join our Care Plan for just

$30.00

per month*
and save $206.00

* One-off registration fee of $58.00 applies

(07) 5591 2262