Fill Out This Quick Form to Make a Payment for Treatment or to Add to a Client’s Spending Account

(Payment must be greater than $20.00 in order to process)

Client Name*
Person Completing Form*
Payment For*
- Treatment Payment
- Client Cash
Payment Amount*
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
What is 2 + 2?*
Total
$0.00
Comments
This field is for validation purposes and should be left unchanged.

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