Payment Request - Patient Portal

Pratice: {{praticeName}}

Please enter the following information.

Account ID

Client Date of Birth

Need help locating your Account ID?

Please see sample below of where to find Account ID on the payment request email or text message you received: Sample Image of Email with Invoice Id

Total Balance {{ balance | currency }}

Other Amount

Payment Amount: {{ amount | currency }}

Account Balance: {{ newBalance | currency }}

Pay with

{{ card.summary }} (expires {{card.expiration}})

I authorize {{ viewModel.groupId }} to save card.

Set as default.

Payment Amount:

{{ amount | currency }}

Partial payment

Payment Method:

{{ creditCard }}.

Payment Date:

{{ paymentDate | date: 'longDate' }}

The payment of {{ amount | currency }} was successfully processed.

Payment Method: {{ creditCard }}.
Reference Code: {{ code }}.

Please double check that your information is entered correctly.

Don't worry, no charges were applied.