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.

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. 

Sample Demo WITHOUT  a service fee.

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

Patient First Name
Patient Last Name
(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
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 *