Bloom Recovery Network
Balance Payoff
Client Name
*
First Name
Last Name
Payment Options Below
ALL PROGRAMS MUST BE PAID IN FULL 7 DAYS PRIOR TO THE PROGRAM START DATE.
MAKE PAYMENT BELOW and THEN SELECT "SUBMIT."
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Initial Deposit
$
50.00
DOUBLE ROOM Full Fee
$
400.00
DOUBLE ROOM Payoff (after -$50 deposit)
$
350.00
SINGLE ROOM Full Fee
$
525.00
SINGLE ROOM Payoff (after -$50 deposit)
$
475.00
ROOM UPGRADE from a single to a double.
Only select this option if you have already paid in full for a double room and want to change to a single room.
$
125.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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