Elizabeth Scott
Payment Form
Account Number (Found on Statement)
Client Name (Patient)
First Name
Last Name
Name on Statement (leave blank if same as client)
First Name
Last Name
Email
Payment Amount
prev
next
( X )
USD
.
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
Should be Empty: