* mandatory fields
  Salutation:   *  
  Name:   *   NRIC no.:   *  
  E-mail address:   *  
  Contact no.:    *   Mobile no.:    *  
  Address:   *   Postal code:   *  
  Occupation:    
  Mode of payment:   *  
  Amount:   *  
 
DIRECT DEBIT AUTHORISATION
I/We hereby authorise you to confirm acceptance/rejection of my DDA to Kwong Wai Shiu Hospital and further authorise Kwong Wai Shiu Hospital to initiate and you to process debits to my/our account each not exceeding the limit indicated even though this may result in an overdraft or an increase of the overdraft on my/our account. You are entitled to dishonour such payments and may at your discretion levy a fee should my/our account not contain the necessary funds. You are under no obligation to ascertain the name on the record of Kwong Wai Shiu Hospital is the same as that provided by me/us and whether or not notice of the bill underlying the debit has been given to me/us.

This authorisation shall continue in force until I/we have expressively revoke it by written notice delivered to you. You may in your absolute discretion terminate this arrangement by written notice delivered to my/our address last know to you.

I/We agree that you shall not be liable for any losses arising from or in anyway connected with you so acting, provided that you act in good faith or unless directly caused by or resulting from you or your employees’ wilful default or negligence.