CLIENT PAYMENT FORM
Name of Client
First Name
Last Name
Client Date of Birth
-
Month
-
Day
Year
Date
Name of Card Holder
First Name
Last Name
Relationship to Client
Please Select
SELF
PARENT/GUARDIAN
LEGAL REP
OTHER
Payment Amount
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( X )
USD
Description
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
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