1 Patient lookup

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.

Last name or patient ID

First name optional

Date of birth

2 Responsible party

Confirm your details

—

Phone—

Email—

Street—

City, state, ZIP—

Statements go to—

Account—

—

Date of birth—

Office—

Coverage—

Plan started—

If anything above is out of date, tell the front desk before you continue. Receipts and reminders go to these details.

3 Payment plan

$0.00

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.

• Payment schedule

4 Payment method

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.

secure card entry 🔒 pay.trxservices.net

Google Pay Apple Pay — pending domain verification

Card number

Name on card

Expiry

CVV

Simulated entry. Any test card works and nothing is transmitted.

5 Authorisation

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

I authorise Horizon City Orthodontics to charge this card for the amounts and on the dates shown above, until this plan is paid. Required. You can cancel at any time by calling the practice. A copy of this authorisation is kept and is available to you on request. See the terms and conditions. Text me about this payment plan — receipts, a reminder before each payment, and a message if one does not go through. Optional. Message and data rates may apply. Reply STOP at any time. Email me news and offers from Practice IQ. Optional, and not required to pay. Unsubscribe at any time.

✎ Sign here — draw your signature, or type your full name below

Signature of the responsible party

✓

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.

Print or save the authorisation Terms and conditions About Practice IQ

A copy has been emailed to . The next payment is taken automatically on . Nothing further is needed from you.

§ Terms

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.