Account Payment

Application Form

Queensland X-Ray accept payments using Mastercard and VISA credit cards.

Title

*Required Field First Name

*Required Field Last Name

Street Address

Suburb/Town

State

Other

Country

*Required Field Postcode

Preferred method of contact:

* Contact Phone

* Email Address

* Patient ID
(found on invoice)

* Invoice No.
(found on invoice)

If paying more than one invoice please list all other invoice numbers below.

Invoice No.

* Amount you wish to pay $

Please click on the Make Payment Button to proceed to our ANZ secure online payment portal.