Online Bill Pay

The easiest and quickest way to get paid

This is a demo page of two possible bill pay solutions for a fictitious dental office.  The form on the right has an added “service fee” feature so you can charge your customer an added fee option which can be used to offset your credit card processing fees.

Test out the form, don’t worry the checkout page is deactivated on this demo.

Please contact us for more information and pricing options.

SAMPLE DEMO WITHOUT A SERVICE FEE

You can now pay your bill online with PayPal.

You don’t need a PayPal account to pay your bill, you can use any VISA or MasterCard debit or credit card.

To pay your bill online all you need is your Chart Number and the patients information.

Pay Dentist Bill Online without Fee
Acme Periodontics
123 Main Road
ANYTOWN, MA 02740
Tel: (555) 555-5555


Patient First Name
Patient Last Name
Address
Address
City
State
Zip
(Must match the email address you entered above)
Payment Date
Chart No.(located at the top of your statement)
S
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 *

SAMPLE DEMO WITH A SERVICE FEE

You can now pay your bill online with PayPal.

You don’t need a PayPal account to pay your bill, you can use any VISA or MasterCard debit or credit card.

To pay your bill online all you need is your Chart Number and the patients information.

Please note that there is a processing fee of $1.50.

Pay Dentist Bill Online With Fee
Acme Periodontics
123 Main Road
Anytown, MA 02740
Tel: (555) 555-5555


Patient First Name
Patient Last Name
Address
Address
City
State/Province
Zip/Postal
(Must match the email address you entered above)
Payment Date
Chart No.(located at the top of your statement)
$
Amount you are paying on your account
Processing Fee *
Online payment processing fee
$
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 Card *
Pay Dentist Bill Online With Fee
Acme Periodontics
123 Main Road
Anytown, MA 02740
Tel: (555) 555-5555


Patient First Name
Patient Last Name
Address
Address
City
State/Province
Zip/Postal
(Must match the email address you entered above)
Payment Date
Chart No.(located at the top of your statement)
$
Amount you are paying on your account
Processing Fee *
Online payment processing fee
$
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 Card *