Appointment Confirmation & Authorization Form Please Complete this form to secure your appointment booking. Patient First Name* Patient Middle Name/s Patient Last Name* Patient Date of Birth* Guardian Title* Mr.Mrs.Ms.Miss.Other if Other Guardian Full Name* Guardian Address* Street Suburb New South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Guardian Email* Guardian Mobile* Payment Authorization by Guardian By Ticking this box, I wish to confirm my appointment, and I authorize The Paediatric Specialists to charge the consultation fees to my Credit Card (details provided below) I further confirm that I am the authorized signatory to the identified Credit Card. Card Type* VisaMastercard Card Holder Name* Card Number* Card Expiry* 0123456789101112 Month 202420252026202720282029203020312031203320342035203620372038203920402041204220432044 Year CVV (required) Please complete this form minimum 3 days prior to your scheduled appointment.Non-completion may result in rescheduling or cancelling your appointment. Credit Card surcharge of 1.5% applies to all Visa and Mastercard payments.
