Payment Plan Agreement

Payment Plan Agreement:

First Name *

Last Name *

Patient Email *

Payment Schedule

Payment Method *Please note transactions through Tyro Health will incur a 2% surcharge, which is payable at the time of deposit, by the account holder

Start Date *

Total Amount of Treatment *

Deposit Amount *

Surcharge AmountOnly applicable for Tyro Health Payment Plans

Total Deposit amount *

Payment Plan Amount *

Next Payment Date *

$ *

Plan Prepared by *Perio Centre Staff Member -

Manager Approval *Perio Centre Staff Member -

I agree to make the required payment/s for the treatment provided by the Perio Centre, on the dates outlined in this document.

I understand that I will receive a email with a payment link/ reminder on the due date, it is my responsibility to make payment within 24 hours of receiving this reminder and provide the Perio Centre team with a copy of my transaction by emailing admin@periocentre.com a recepit will be provided on recipt of the funds.

I UNDERSTAND THAT IF A SCHEDULED PAYMENT IS DEFAULTED, THE PAYMENT PLAN WILL BE VOIDED AND NEW TERMS WILL BE AGREED UPON TO ENSURE PAYMENT IS FINALISED WITHIN THE PAYMENT TERMS.

Signature *

Draw signature|Type signatureClear

Date *

Patient Entered onto Tyro Health *

Staff Member who finalised plan: *

Notes: