You can always press Enter⏎ to continue
Lane Orthodontics Payment Form
Payments made easy
START
1
Patient's Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
How much would you like to apply to your account today?
If you would like amount to be applied to multiple patients please leave a note under "Additional Requests"
prev
next
( X )
Description
USD
Enter Amount
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
Previous
Next
Submit
Press
Enter
3
Email
A confirmation of payment and receipt will be sent here
example@example.com
Previous
Next
Submit
Press
Enter
4
Additional Requests
example: Need FSA receipt, Apply payment to additional children, etc.
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
4
See All
Go Back
Submit
