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PAY BILL
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Pay Bill
Aside from the Patient Portal, below is an alternative 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.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Patient Name
*
First
Last
Date of Birth
*
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your for: of
This payment is for:
*
Myself
My child or spouse
Other
Your Name
*
First
Last
Individual filling out this form
Email
*
For emailed receipt of payment
Amount to pay:
*
Details regarding your payment
Therapist's Email
If you want your therapist to receive a notification of your payment, select their email address above,
Credit Card or PayPal
*
PayPal Checkout
Credit Card
Card Number
Expiration Date
Security Code
Cardholder Name
Billing Address
*
Address Line 1
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Authorizations
*
I authorize the payment of this amount for the patient listed above.
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