temp cc | The Victorian College of Classical Homeopathy

Book online for consultation

Name of patient:
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Name of person booking (if different):
Relationship to the patient:
Address Line 1:
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Address Line 2:
City:
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State:
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Country:
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Postcode:
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TimeZone:
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Phone Number:
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Email Address:
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Repeat Email Address:
*
PLEASE:

Deposit:
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First time booking –tick all three boxes.
Existing patient updating details – tick follow up only

Please debit my credit card AUD$50 as deposit for consultation - this payment is a deposit and taken from the balance of the first consultation. A consultation time will be sent to you - you may request a change of appointment time - this deposit holds you a place in the consultation system for a period of six months from the date of this booking and is non-refundable after seven days of this booking. The booking deposit can be transferred to another new patient or existing patient if required.

Balance:*
The balance of payment for consultation is AUD$130. I acknowledge this credit card will be used to pay the balance once I email my completed case proforma with photos.
Follow-up:*
Please debit my credit card AUD$100 for each follow-up consultation.
Card Type:
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Card Number:
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Card Holders Name:
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Please provide the 3-digit CVV (Customer Verification Value). This is the non-embossed number printed on the signature panel on the back of the card immediately following the Visa or MC card account number.
Card Verification Code:
*
Expiry:
/ *


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