Secure Online Payments

Payment Information
Description	Billing
Payment Amount	Frequency When will monthly payments start? How long will payments go? How many monthly payments?

Contact
First Name*
Last Name*
Email*
Verify Email*
Birthday*
Two Accounts

Billing Address
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

Check To Confirm

Please check the box to confirm you want to schedule Monthly Payments and not be charged at this time.

Enter /Your Full Name/
to Sign and Authorize.

*Required

I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Colfer Chiropractic Wellness Center Terms as referenced in the [Terms of Use] link below.

Colfer Chiropractic Wellness Center
120 Shelton McMurphey Blvd. Suite 320 Eugene, OR 97401
(541) 345-9401

To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.