PAY BILL

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

Payment made here will either be applied to the invoice # entered below or to the oldest outstanding balance on the patient’s file if no invoice is entered.
We use PayPal to process these payments, and you will receive an email confirmation of your payment.
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 *//

Invoice Number

(This is optional. If the invoice entered here matches with an outstanding invoice on file, the payment will be applied to that invoice. If nothing is entered here, the payment will be applied to the oldest outstanding balance on the patient's file)

Amount: *

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).

PAY BILL

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

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