Visit Payment
Make a payment for your visit below. If you are not sure how much to pay, contact your specific clinic location directly.
Primary Clinic
*
Boulder
Broomfield
Englewood
Lafayette
Longmont
Wheat Ridge
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Date of Visit
-
Month
-
Day
Year
Date
What is this payment for?
*
If you are not sure, contact your clinic directly
Physical Therapy Visit
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( X )
USD
Enter Payment Amount
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Submit
Should be Empty: