Out Patient Invoice Payment
If you have questions, please contact contact@apot-wny.com
Child's Name
*
First Name
Last Name
Guardian's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
What was the session?
*
OT
PT
Enter amount to be paid:
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( X )
Out Patient OT/PT Service - 30 minutes
$
80.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Submit
Should be Empty: