Find the patient
Enter the name and date of birth together, the way you would confirm them out loud. Nothing appears until both match one person.
Confirm your details
If anything above is out of date, tell the front desk before you continue. Receipts and reminders go to these details.
| Total price of the treatment plan | |
| Paid so far | |
| Outstanding | |
| Payments left after today | |
| Final payment |
This figure is read from your plan in the practice’s own system. It is not calculated on this page and cannot be changed by it.
Card details
Your card is entered on the payment processor’s own secure page. The practice and Practice IQ never see or store your card number.
Simulated entry. Any test card works and nothing is transmitted.
Authorise this payment plan
Review the terms below, then sign. A copy is retained by the practice and is available to you on request.
| Total price of the treatment plan | |
| Charged today | |
| Then | |
| Final payment | |
| Card | — |
| Cancel or change | (915) 555-0142 |
Payment authorised
Receipt
| Paid today | |
| Card | |
| Authorisation code | |
| Reference | |
| Patient | |
| Posted to the practice ledger | ✓ posted |
What you agreed to
| Charge this card on the dates shown | |
| Text messages about this plan | |
| Marketing email from Practice IQ | |
| Signed |
The two optional items were not a condition of payment and could be declined without affecting this plan.
A copy has been emailed to . The next payment is taken automatically on . Nothing further is needed from you.
Payment plan terms
Sample terms for demonstration. A live deployment carries the practice’s own agreement, reviewed by their counsel.
| Who you are paying | Horizon City Orthodontics |
| What is charged | The amounts and dates shown on your plan |
| How to cancel | Call (915) 555-0142 at any time |
| If an amount changes | You are told before the next payment is taken |
| Your card | Held by the payment processor, not by the practice |
| Your copy | Kept on file and available on request |
Card details are captured by TRX Services on their own systems. Neither the practice nor Practice IQ receives or stores your card number. A stored card is used only for the payments on this plan.