Payment Page - Independence Plus

One Time Payment
Monthly Recurring Payment
Bi-Weekly Recurring Payment
Weekly Recurring Payment

One-Time Payment

You are about to make a one-time payment.

First Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Patient Name *

Amount *$

*Indicates field is required

Monthly Payment

You are about to make a monthly recurring payment.

First Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Patient Name *

Amount *$

*Indicates field is required

Bi-Weekly Payment

You are about to make a bi-weekly recurring payment.

First Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Patient Name *

Amount *$

*Indicates field is required

Weekly Payment

You are about to make a weekly recurring payment.

First Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Patient Name *

Amount *$

*Indicates field is required