PAY BILL

Below is a simple way to pay some or all of your bill.

We use PayPal to process these payments, and you will receive an email confirmation of your payment.
Unless specified in the Details box below, payment made here will be applied to the oldest outstanding balance on the patient’s file.
If you select your therapist’s email below, they will also receive an emailed confirmation of your payment.

Patient Name *

First

Last

Date of Birth *//

Amount: *

Details regarding your payment

Email *

For emailed receipt of payment

Therapists Email

If you want your therapist to receive a notification of your payment, select their email address above,

Your Name *

First

Last

Individual filling out this form

Authorizations *

I authorize the payment of this amount for the patient listed above. (You will be taken to PayPal to complete your transaction).

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