temp cc | The Victorian College of Classical Homeopathy

Book online for consultation

Fill out all fields (or choice of fields) with a red star. When complete, enter “submit”. You will be directed to a new webpage with confirmation of your booking and will receive a confirmation email. We will email you with patient instructions within 2 working days. Check your spam folder for our email. If you are experiencing any issues, please CONTACT US
Name of patient:
*
Name of person booking (if different):
Relationship to the patient:
Patient date of birth:
*
New or existing patient:
New
Current patient*
Address Line 1:
*
Address Line 2:
City, town or suburb :
*
State:
*
Country:
*
Postcode:
*
TimeZone:
*

Note:

Where possible please enter both Mobile/Cell and Landline number.Remember to add country and state code. Example +613 9000 0000 landline and +61 (0)123 123 123 mobile/cell.
Phone number (landline):
Phone number (cell or mobile):
*
Email Address:
*
Repeat Email Address:
*
Would you like text reminders for appointments?
Yes
No
PLEASE:

Deposit:
*
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.

Balance:*
The balance of payment for consultation is AUD$160. 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$120 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:
*
Expiry:
/ *


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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