Alliance Maintenance Plan Form

Section 1 - Patient Details

Patient Id

Title

Forename

Surname

Email Address

Mobile Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth

Prefered Contact Method

Section 2 - Membership Plan Details

Start Date

Payment Frequency

Dentist Name

Select Your Plan

Section 3 - Patient / Payers Declaration

By signing below, the Patient (or Payer where this form is completed for a child) agrees to the Plan Terms and Conditions. Where the Patient is not paying for the plan, by completing their details and signing the Direct Debit Instruction overleaf, the Payer agrees to make regular payments on behalf of the Patient and receive correspondence relating to those payments.

Signed by the Patient / Payer

Signed by or on behalf of the Dentist

Date

Is the Patient paying for their own plan or is someone else paying on their behalf?

Section 4 - Payer Details

(only complete if the Patient is not paying for their own plan)

Title

Forename

Surname

Email Address

Mobile Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth

Prefered Contact Method

As the payer if you are/will be a plan holder would you like this patient to be grouped to your plan record, including for payment purposes?

Direct Debit Instruction

Instruction to your Bank or Building Society to pay by Direct Debit

To: The Manager

Service User Number- 5 3 7 3 5 8

Reference Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Account Holder's Name

Bank/Building Society Account Number

Branch Sort Code

Instruction to your Bank or Building Society
Please pay ALLIANCE DENTAL CARE LTD Direct Debits from the
account detailed in this Instruction subject to the safeguards
assured by the Direct Debit Guarantee. I understand that this
Instruction may remain with ALLIANCE DENTAL CARE LTD and if so,
details will be passed electronically to my Bank/Building Society.

Signature

Date

I agree to the Terms & Conditions

69-75 Dyke Rd, Brighton and Hove, Brighton

69-75 Dyke Rd, Brighton and Hove, Brighton

Alliance Maintenance Plan Form

Alliance Maintenance Plan Form

Section 1 - Patient Details

Section 2 - Membership Plan Details

Section 3 - Patient / Payers Declaration

Section 4 - Payer Details

(only complete if the Patient is not paying for their own plan)

Direct Debit Instruction

Instruction to your Bank or Building Society to pay by Direct Debit