OHP Assessment

OHP Assessment Pre-Pay (For Meddbase OH Portal Clients)
The purpose of this form is to allow Clients who utilise our Meddbase OH Portal to Pre-Pay prior to submitting referral via the Meddbase OH Portal.

Client Instructions :
- Please complete the Payer Details, Patient Details and Credit Card details below and Submit.
- Once you have successfully completed the payment you will receive an email receipt.
- You should then complete the Referral in the Patient Portal (Portal Link).
- Cognate Customer Services will arrange the Appointment with the employee and communicate details to you.
Enter your details below to make a payment. Once you make a payment details of the appointment will be forwarded to the Employee email address entered.
Service Name*
UniqueID
Payer Details
Name*

First NameLast Name
eMail Address*
Payment Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Company*
Patient Details
Patient Name*

First NameLast Name
Type*

My Products*

OHP Assessment

€295.00

Total

€0.00

SSL Secure Payments by Square. We do not store your Credit Card Details.
1. Once you have successfully completed the payment you will receive an email receipt. ***** Please check your SPAM folder. **********
2. You should then complete the Referral in the Patient Portal (Portal Link).
3. Cognate Customer Services will arrange the Appointment with the employee and communicate details to you.
Should be Empty:

OHP Assessment Pre-Pay (For Meddbase OH Portal Clients)