Payment Form — GMD CLINICS

Payment Form.

If any problems filling out the form please email us for a pdf attachment.

This payment form is needed for non-eligible children. A discounted payment from $169 to only $69 for a limited time.

School/Day-Care Name

Child Name

First Name

Last Name

Child Date of Birth

Message

Parent/ Guardian Name

First Name

Last Name

I consent for my child to be seen by Dentist/Therapist

Check-up

Clean & polish

Name on the card

First Name

Last Name

Card Number {Only numbers No spaces}

Expiry Date

YYYY

CCV

Phone Number