Client Payment / Automatic Draft Form

To make a payment or set up a payment plan, please complete and return the form below.

Sender Email*:
*A copy of this completed form will be sent to your provided Sender Email address.
Client Payment / Automatic Draft Form
Provider Name: Patient Name:
Date of Service to Apply Payment: Patient Address (verified, no changes):
Patient Phone (verified, no changes):
Card Type: VISA MasterCard Discover Care Credit
Card Number: Expiration Date:
Security Code: Zip Code:
Payment Amount: Receipt to be mailed? YES NO
Payment Plan. Auto Debit.
I agree to the below outlined payment arrangement to satisfy the current outstanding balance on my account.
Payment Amount: Arrangement Start Date:
Payments shall be run: Biweekly (on Fridays) Monthly (the 28th of each month)
Signature of Responsible Party: Date: