PAY ONLINE

Patient Balance or Self-Pay Programs

Pay Patient Balance

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

SELF-PAY PROGRAMS

Click here if you are paying for:

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

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:	*
Account Number:	* what's this?
Message (255 Characters):
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?