Active Family Chiropractic & Acupuncture

Payment Information

Pay your bill using this secure online form.

Amount

Frequency

When will monthly payments start?

How long will payments go?

How many monthly payments?

Contact / Shipping

Birth Date

Billing Address

Billing

what's this?

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.

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

Active Family Chiropractic & Acupuncture
705 North Webb Road Grand Island, NE 68803-3311
(308) 384-4955

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.