Update to Patient Payments Form
We have updated our Patient Payments Form so you will receive an auto responder to your submissions.
We have added an email address field that you must enter every time you submit a Patient Payments Form.
After you submit the form, you will receive email confirmation with the subject: Patient Payments Form Confirmation. The body of the email will look like the below, which will display the date and time (Pacific Coast Time) you submitted the form, your office name, and the names of the patients with a breakdown of the payments. It is suggested you create a separate folder in your email program to save these emails for easy reference.
| Record ID: | 5081 |
| Date Submitted: | 7/30/17 5:15 AM |
| lFUUID: | 284dbcb7-8497-4cb7-ba7e-e526d8bff24e |
| Office Name: | Jones Chiropractic |
| Email Address: | mbpros@gmail.com |
| Patient 1 Name: | John Smith |
| Patient 1 Payment Date: | 1/1/2017 |
| Patient 1 Payment Method: | Credit Card |
| Patient 1 Check Number: | |
| Patient 1 Payment Amount: | $50.00 |
| Patient 2 Name: | |
| Patient 2 Payment Date: | |
| Patient 2 Payment Method: | |
| Patient 2 Check Number: | |
| Patient 2 Payment Amount: | |
| Patient 3 Name: | |
| Patient 3 Payment Date: | |
| Patient 3 Payment Method: | |
| Patient 3 Check Number: | |
| Patient 3 Payment Amount: | |
| Patient 4 Name: | |
| Patient 4 Payment Date: | |
| Patient 4 Payment Method: | |
| Patient 4 Check Number: | |
| Patient 4 Payment Amount: | |
| PDF Value (Patient Payment Form): | patientpaymentform_20170730_051503590.pdf |
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