Apply for debt collection service

Please fill out the form below to apply for debt collection services with Medical Practice Debt Collection. Once your form has been submitted, our team will evaulate it and contact you shortly with more information on our service.

Application form

Full name:

E-mail address:

Contact number:

Debtors book balance:

Number of debtors:

Debtors ageing:

30 days	60 days	90 days	120+ days
R	R	R	R

Comments:

Med-e-Mass client:

Tick this box if you are a Med-e-Mass client

All fields are required