Refund Request Form

Fill in the form below (* Required) and our accounting team will process your request within 14 business days. Once we have processed the refund, we will send you an email confirmation.

PATIENT DETAILS
Patient Name*
First Last
Patient - Date of Birth:*
Patient - Mobile Number*
For verification purposes
Patient - Email Address*
For verification and notification purposes
Patient - Residential Address
For verification purposes

Street Address Suburb State Post Code
Last (or Upcoming) Appointment Date*
For verification purposes
Requested refund amount*
Please only enter the amount for the consultation fee. Please note that card surcharge is not refundable.
CREDIT / DEBIT CARD DETAILS
Please provide your CREDIT or DEBIT details. The cardholder MUST be under the patient or the patient's parent (if patient is under 14 years old)
Cardholder Name*
First Last
Credit or Debit Card Number*
VISA, MASTER or EFTPOS
Expiry Date*
Reasons for refund:*
Message (Optional)

Refund Request Form

PATIENT DETAILS

CREDIT / DEBIT CARD DETAILS