Pay 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

your for: of

This payment is for:

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

Card Number

Expiration Date

Security Code

Cardholder Name

Billing Address

Address Line 1

City

State

Zip Code

Authorizations