denticare form

Responsible party for payments

A Responsible party must be an Australian citizen, employed, 18 years of age or older and not subject to bankruptcy or any debt agreements.

The Payment Plan

followed by the Direct Debit Amount above each

Week Fortnight Month

A one off $49 set up fee will be charged with the first payment.

I, the Responsible Party as detailed above, agree to the Payment Plan as set forth in above section.

Please sign:

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