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Client (Provider) Name
*
Practice / Company Name
Payment Amount
*
How would you like to pay?
*
Credit Card
Electronic Check (eCheck)
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
Exp. Date (mm/yy)
*
CVV2
*
🛈
Name as it appears on card
*
Billing Street Address
*
Billing ZIP
*
Name of Financial Institution
*
Account Type
*
Business Checking
Business Savings
Personal Checking
Personal Savings
Transaction Date
*
+
Routing Number
*
Account Number
*
Name on Account
*
Phone Number
*
Would you like to receive an email receipt for this transaction?
*
Yes
No
Please provide your email address
*
NOTE:
A receipt for this transaction will be sent to this email address after your payment has been processed.
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