Credit Card Payment Form

    The form is to authorise a credit card payment to Clinical Psychology Victoria when the owner of the card is not present. It is to be signed and sent for each and every payment where the credit card is used without the owner present.

    You must ensure that the amount due stated below is consistent with the fee payable. If you are uncertain or if you would like to pay directly, please call the reception on (03) 5443 1090.

    All fields are required to be completed to send this form.

    Card Number
    Expiry Date
    CVV (3 numbers on the back of the card)
    Card Holder’s Name (as it appears on the card)

    Card Holder’s Address
    Card Holder’s Email
    Card Holder’s Phone

    Total Amount

    I authorise Clinical Psychology Victoria to debit my credit card with the amount shown above. I certify that I am over 18 years of age.

    Would you like a receipt to be emailed to you?

    Please note that when you email Clinical Psychology Victoria the content of your message, as it is transferred across the internet, may not be secure. If you have any concerns you can contact our office directly at (03) 5443 1090 or