Only complete this online application if you are the account holder and only one signature is required to authorise a Direct Debit.

Please ask a member of staff if:

• you are not the account holder or more than one signature is required
• you already have a Direct Debit Instruction setup and want to add or remove a patient
• you have any questions

We use session cookies to carry information across pages of your sign-up. These cookies delete themselves automatically when you leave a website and go to another, or when you shut down your browser.