Payment plans

Denticare application form

Please fill out this form which will help our front office set up your Denticare payment plan.

Full Name *

Mobile Phone number *

Email (optional)

Total amount applying for (including 20% deposit) *

Are you (or the responsible party) an Australian citizen? * Yes No

Are you (or the responsible party) employed? * Yes No

When is the best time for the scheduled payment to be withdrawn from your account? *

When is the best date to start the scheduled payments? *

Can be up to 6 weeks from the application date.

Will the payments be coming out of your personal account? * Yes — my account No — someone else's

The details you send are used only to set up your Denticare payment plan. They go securely to our front office team and are never shared with anyone else.

Back to Denticare info

Prefer to talk it through?

No problem — call us on 07 4635 1444 or ask at your next appointment and our front office team will set your plan up for you. You can read how Denticare works on our Denticare page, or compare all your options on payment plans.

Denticare application form

Thank you — we've got your application

Prefer to talk it through?