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 Name
Last 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
*
-
Month
-
Day
Year
Date
Chart Number
*
Person making this payment
*
First Name
Last Name
Signature of person making this payment.
*
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
1
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5
6
7
8
9
10
Submit
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Should be Empty: