Mateus Web Design – Bill Pay Online

Online Bill Pay

The easiest and quickest way to get paid

This is a demo page of a bill pay solutions for a fictitious dental office.

Use the demo credit card numbers displayed below to see how the online bill paying form works. Enter your email address to receive a “receipt” of the payment.

Please contact us for more information and pricing options.

PAY YOUR BILL ONLINE

You can now pay your bill online.

Pay your bill with any VISA or MasterCard debit or credit card.

Please have your Invoice or Chart Number to pay your bill.

Click Here to Test Demo "WITH" a Service Fee

Sample Demo WITHOUT a service fee.

Pay Dentist Bill Online without Fee

Acme Periodontics
123 Main Road
ANYTOWN, MA 02740
Tel: (555) 555-5555

First Name *

Patient First Name

Last Name *

Patient Last Name

Address

City

State

Zip

Email (We will send you a copy of your payment to this email address) *

Confirm Email (We will send you a copy of your payment to this email address) *

(Must match the email address you entered above)

Phone Number

Date

Payment Date

Chart Number *

Chart No.(located at the top of your statement)

Payment Amount *

Amount you are paying on your account

To test out the credit card payment please use the following demo information:
credit card number: 4242 4242 4242 4242
Expiration Date: Use any date
Security Code: Use any security code.

Credit/Debit Card Information *