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The Direct Debit Guarantee
This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme.
Name(s) of Account Holder(s)
Branch Sort Code
Bank/Building Society account number
Originators Identification Number
Reference Number (For Office Use)
Instructions to your Bank or Building Society Please pay Insurance Broking Finance Ltd Direct Debits from account detailed in this instruction subject to the safeguards assumed by the Direct Debit Guarantee. I understand that this instruction may remain with Insurance Broking Finance Ltd and, if so, details will be passed electronically to by Bank/Building Society.
The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society.
If the amounts to be paid or the payment dates change Insurance Broking Finance Ltd will notify you 12 working days in advance of your account being debited or as otherwise agreed.
If an error is made by Insurance Broking Finance Ltd or your Bank or Building Society, you are guaranteed a full and immediate refund from your branch of the amount paid.
You can cancel a Direct Debit at any time by writing
Banks and Building Societies may not accept Direct Debit Instructions for some types of account.
to your Bank or Building Society. Please also send a copy of your letter to us.
Insurance Broking Finance Ltd. Registered in England No. 04981657. Registered Office: Affinity House, Bindon Road, Taunton, TA2 6AA
This is our standard agreement upon which we intend to rely.
For your own benefit and protection you should read these terms, which continue overleaf, carefully before signing them.
By signing this form you are also consenting to the use of personal
information as described in clause 4.1 overleaf and are opting to receive marketing information from the Practice.
If you do not wish to receive marketing information from the Practice please tick the box.
Patient Signature Date
Monthly Fee: £15 Joining Fee (if applicable): £ Date of Commencement: / /
Signed On Behalf Of The Practice
1. Fees payable by the Patient
1.1 The Patient will pay the Practice a Monthly Fee of £15, as stated overleaf for the services listed in 2. below.
1.2 Payments will be taken by Direct Debit, through Insurance Broking Finance Ltd, who administer the direct debit facility on behalf of the Practice.
1.3 The first payment may be taken up to 2 months after the date of this Agreement due to administrative reasons and will consist of a “double payment” to include payment for the first and second months.
2. Services provided by the Practice
2.1 In consideration of the fees outlined in 1.1 above, the Practice agrees to provide the dental services described in 2.2 below either through the Dentist or by a suitably qualified partner, member of staff, deputy or locum.
2.2 The services to be provided are:
• 4 Hygiene appointments
• 5% discount on treatment
• Accident & Emergency Dental Cover
2.3 For the purposes of clause 2.2, years will run from the date of this Agreement and each anniversary of that date.
2.4 The fees paid under this Agreement do not cover costs associated with treatment which has been specifically agreed to be excluded between you and your Dentist, orthodontic appliance therapy, dental implants and related superstructures, treatment which is purely cosmetic, treatment carried out at another Practice (other than for temporary emergency treatment covered by the insurance as described in 2.2 above), pharmaceutical items, laboratory fees, prescription fees, extraction of wisdom teeth, sedation fees, or referral to specialists. These would be charged for separately.
3. Responsibilities of the Patient
3.1 You must pay the Monthly Fee. If the Direct Debit cannot be taken, then all benefits under the Plan will cease from the date it was due to be taken.
3.2 You are responsible for ensuring that you make appointments with the Practice. There will be no refunds for
any “unused” services, nor can they be carried forward from one year to another.
3.3 You must keep appointments made with your dentist or pay the appropriate missed appointment fee. Any late cancellations may be subject to cancellation fee.
4.1 Administration of this scheme is undertaken (on behalf of the Practice) by Lloyd & Whyte Ltd and Insurance Broking Finance Ltd (in respect of arranging the Accident & Emergency Insurance and collection of Direct Debits respectively). By signing this agreement you consent to these companies using the data you provide in order to complete such administration, but your personal details will not be used by them for any other reason.
4.2 Lloyd & Whyte Ltd and Insurance Broking Finance Ltd are not party to this Agreement and as such have no liability to the Patient (whether in respect of negligence, breach of contract, defective or unsatisfactory treatment or otherwise) but they may rely on the provisions of this Agreement despite the terms of the Contracts (Rights of Third Parties) Act 1999.
5.1 Any complaints should be made in writing to the Practice. Such complaints will be treated fairly and promptly.
6. Changes to the Plan
6.1 The Practice may change the fees payable or extent of services provided under this agreement at any time. The Patient will always be given at least one month’s Notice of such changes. Under normal circumstances, fees would only be changed once each year.
6.2 Any Notice will be deemed to be valid if sent to your last known address by ordinary post.
7.1 Either the Practice or Patient can terminate this Agreement at any time, with one months Notice.
7.2 If Direct Debits cannot be taken from the Patient, then the Patient will be deemed to have terminated this
7.3 On termination of this Agreement:
• All Services will cease immediately
• If less than 12 months have passed since the commencement of this Agreement, and termination is by the Patient rather than the Practice, then the Patient will be responsible for paying any difference between the amount of fees paid and the Practice’s
standard costs for Services used.
• There will be no refund for any “unused” Services.
7.4 If a patient wishes to re-join the Plan, then this is at the discretion of the Practice and may incur a charge which would be advised prior to re-joining.
8. Change of Dentist
8.1 The Patient may request to change to a different dentist within the Practice. If that dentist agrees to treat the Patient under this Plan then the new dentist shall become the Dentist for the purpose of this Agreement.
8.2 If the Patient moved to a different practice, then this Agreement will terminate. This Agreement is not transferable.
9. Governing Law & Jurisdiction
9.1 This Agreement is governed by and constructed in accordance with English Law and the parties hereby irrevocably submit to the exclusive jurisdiction of the English Courts.