Ausmile Mobile Dental Care

Payment Authorization Form

Parent Name:

Child Name:

DOB:

Address:

Email:

School:

Phone:

Card Number:

Expiry (MM/YY):

CCV:

I, , authorise to pay $89 (reduced fee) for my child's Checkup and Clean by Ausmile Dental Clinic, reduced from $179.

Signature:

Date:

Email: ausmilemd@gmail.com Website: www.ausmile.com.au