EEG Test Pre-Payment - Clinical Neurology Services

Use this form to securely pre-pay for your EEG Test online.

"*" indicates required fields

Name*

First Last

Phone*

Email*

EEG Appointment Date*

Billing Address*

Street Address City State ZIP Country

EEG Test – Initial Deposit Fee*

Price:

Please note that the fee mentioned above is the initial deposit to secure your appointment date. The total cost for the EEG Test is $350.00

Processing Fees

Price: $ 0.00

Please note there will be a payment gateway surcharge of 1.75% + 30c

Invoice Total

Credit Card*

Card Details

Cardholder Name

Comments

This field is for validation purposes and should be left unchanged.

Suite 1, Karrinyup Specialist Centre 184 Karrinyup Road, Karrinyup WA 6018
Phone:	6184 1818
Fax:	6184 2828
Email:	admin@clinicalneurology.com.au