Old West Credit Card Payment form
Please fill out the form to pay with a card.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Date of your appointment so I can give you credit for the deposit or payment.
-
Month
-
Day
Year
Date
Make a Payment ( You can also pay Cash or Venmo if you would rather)
Categories:
All
All
Deposits
Full Payment
Remainder amount payments
prev
next
( X )
tip in $5 increments ( Not required of course!)
$
5.00
Quantity
1
2
3
4
5
6
7
8
9
10
$5
$10
$15
$20
Deposits
deposit for sessions 1 or 2
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
deposit session 3
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
deposit session 4
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Session 5 deposit
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Full Payment
session 1
15 minutes
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
session 2
30 minutes
$
200.00
Quantity
1
2
3
4
5
6
7
8
9
10
Session 3
30 minutes + USB
$
220.00
Quantity
1
2
3
4
5
6
7
8
9
10
Session 4
1 hour +usb
$
400.00
Quantity
1
2
3
4
5
6
7
8
9
10
Session 5 with approval only
$
500.00
Quantity
1
2
3
4
5
6
7
8
9
10
Remainder amount payments
remainder balance session 1
already paid the deposit, this is the remainder
$
85.00
Remainder balance session 2
already paid the $15 deposit, this is the remainder
$
185.00
Remainder balance Session 3
already paid the deposit of $25 for this session and now you need to pay the remainder
$
195.00
Remainder balce Session 4
already paid the $50 deposit and this is the remainder
$
350.00
Submit
Should be Empty: