temp cc | The Victorian College of Classical Homeopathy

Book online for consultation

Name of patient:
Name of person booking (if different):
Relationship to the patient:
Address Line 1:
Address Line 2:
Phone Number:
Email Address:
Repeat Email Address:

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

Please debit my credit card AUD$65 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.

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.
Please debit my credit card AUD$110 for each follow-up consultation.
Card Type:
Card Number:
Card Holders Name:

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:
/ *

We would appreciate it if you could indicate where you found out about us or this service:

If 'Other', please specify:

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