Powell Chiropractic Payments - set amount

Powell Chiropractic Payments - set amount

Set Payment on Account

This payment option will allow you to make a payment on your account. If you want to pay the FULL AMOUNT of your statement and you do not see that option on this form please call 888-558-3188 x3. An account specialist will take your payment information to process.
Patients Name*

First NameLast Name
Email of contact for this patient*
example@example.com
Phone of contact for this patient*
Please enter a valid phone number.
Date of Birth of this patient*

MonthDayYear
Date
Chart Number*
Person making this payment *

First NameLast Name
Signature of person making this payment.*

Clear
Person making payment.
Payment Options
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Payment On Account of $5.00
You are paying $5.00 on your account.

$5.00



Payment On Account of $10.00
You are paying $10.00 on your account.

$10.00



Payment On Account of $20.00
You are paying $20.00 on your account.

$20.00



Payment On Account of $50.00
You are paying $50.00 on your account.

$50.00



Payment On Account of $75.00
You are paying $75.00 on your account.

$75.00



Payment On Account of $100.00
You are paying $100.00 on your account.

$100.00



Payment On Account of $150.00
You are paying $150.00 on your account.

$150.00



Online Payment Fee
This is a convenience fee for online processing

$1.00 Quantity



Subtotal

$0.00

Shipping

$0.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty: