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Make Payment
1
Patient
Info
2
Receipt
Patient
Amount to pay
First name
Last name
Account num.
Email address
(To email you a receipt. This is optional. And we respect your privacy.)
The account number is at the top right of your invoice.
/* Developers: do a check that the acc num and last and combination are found in the database. */
Invoice number(s)
Payment amount
If you are unable to pay the full amount owed, make a partial payment.
Then, contact Spring Manor at tel: (847) 555-1234. Let us know when to expect the remaining payment.
Which invoice do you want to pay? Separates multiple invoice numbers with commas, like this: 5045, 5089
Method of payment
Card number
Expiration
Credit card
CVC
eCheck (ACH)
Account type
Routing number
Bank account number
-- or --
Name on Bank Account
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