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Payment Form

This payment form is needed for non-eligible children. A discounted payment from $199 to only $99 for a limited time.

YOU CAN TRANSFER $99 to the following account:

QLD MOBILE DENTAL CLINICS:

BSB:062223

Account Number: 11639315

Child Name

Child Date of Birth
Day
Month
Year
I consent for my child to be seen by Dentist/Therapist
Expiry Date
Day
Month
Year
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