Pay online

Payment Form

Pay Patient Balance

This form is to remit your patient balance;
you must have your patient ID number to complete this transaction.

Click here if you are paying for:

Fitness for Life	Golf for Life
Personal Training	Throwers Performance(TAP)
Video Gait Analysis	Sportsmetrics

If the program you are paying is not listed above, click here to make payment.

If you have a question regarding your payment please contact us.

* denotes required field

Patient Information
First Name:	*
Last Name:	*
Address:	*
Address (line 2):
City:	*
State:	*
Zip Code:	*
Patient ID:	* what's this?
Message:
Billing Information
	Copy from above
First Name:	*
Last Name:	*
Address:	*
City:	*
State:	*
Zip Code:	*
E-mail:	* (A receipt will be sent to you)

Amount:	*
Credit Card #:	*
Expiration:	*
CVV Security Code:	* what's this?