Circumcision Brisbane

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GentiCare Payment Plan

Gentle Procedures are the only clinic in Queensland to offer a hassle free, stress free payment plan. Apply Today!

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GentiCare Payment Plan Application Form

For all enquiries relating to a Circumcision please complete all fields below.
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GentiCare Payment Plan Application Form

Gentle Procedures Clinic Queensland offer a payment plan for procedures performed at all of our locations.You have the option of a weekly payment plan or a fortnightly payment plan. The maximum period of a payment plan is six (6.) weeks or three (3.) fortnights. All Payment Plans incur an establishment fee and a transaction fee.

Patient Details(Required)
DD slash MM slash YYYY
Your Details(Required)
What is your relationship to the patient?(Required)
As you are completing this form your details are required.

* IF YOU DO NOT HAVE A MEDICARE CARD FOR THE PATIENT ENTER THE NUMBER 0 TEN TIMES
Medicare Card Expiry Date mm/yyyy(Required)
DAY ALWAYS SELECT (1)
Patient Medicare Card Reference Number
Number to the left of the name
Parent / Patient / Guardian Home Address

Hidden

Next Steps: Install the Stripe Add-On

To accept payments on this form you will need to install the Stripe payment add-on. Important: Delete this tip before you publish the form.

You are required to provide payment details to setup your payment plan. You must have available funds for the payment plan to be approved.

The maximum term for a payment plan is six (6.) weeks or three (3.) fortnights.
GentiCare Payment Plan Schedule(Required)
Please select the option of paying six weekly payments or three fortnightly payments. You are required to make your first payment at your appointment prior to the procedure being performed.
GentiCare Payment Plan Terms & Conditions(Required)
Please ensure you read and understand your obligations for a GentiCare Payment Plan.If you do not agree with any of the terms we recommend you cancel your application.
Do You Want to book an appointment now?(Required)
If Yes which location do you want to attend?(Required)
Appointment Time Preference(Required)
When would you. like to schedule your appointment?

This field is for validation purposes and should be left unchanged.
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