Please complete the forms below to authorise your Direct Debit.


Title  
First name*      * denotes a required field.
Initials  
Surname*  
     
Postcode*  
     
Address 1*  
Address 2  
Address 3  
Town*  
County / Area  
Country  
     
     
Telephone number* UK Telephone Land Line Only (No Spaces)
Mobile number UK Mobile Number Only
e-mail*  
 


* Required Fields
Direct Debit Logo

Instruction to your Bank or Building Society to pay by Direct Debit


Victory House
400 Pavilion Drive
Northampton Business Park
Northampton
NN4 7PA 01604 684960
Service user number:
Your Membership Number:
   
* Name of account holder(s)
* Sort code
* Account number
   
NOTE: Your account number and sort code will identify your bank and branch address.
Instructions to your Bank or Building Society to pay by Direct Debit.

Please pay Physio First Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Physio First and if so, details will be passed electronically to my Bank/Building Society.

NOTE: Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts.

24 Jun 2024




  • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
  • If there are any changes to the amount, date or frequency of your Direct Debit Physio First will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Physio First to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
  • If an error is made in the payment of your Direct Debit, by Physio First or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society
  • If you receive a refund you are not entitled to, you must pay it back when Physio First asks you to.
  • You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.



*Check Authorisation
Please check this box to confirm that you are authorised to submit this Direct Debit agreement.

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