Invoice Payment
PAYMENT FOR SERVICES RENDERED
Payment Amount
Billing Information
Account Number
Patient First Name
Patient Last Name
Billing Address
Billing Zip Code
Email Address
Additional Comments (Optional)
Payment Information
Name on Card/Check
Pay by Credit Card
Card Number
CVV
Exp.
Month
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
We Accept:
Pay by Electronic Check
Routing Number
Checking Account Number
Submit Payment
McKim Chiropractic
2023 12th Ave. Rd.
Nampa, ID 83686
Phone: (208) 467-5756
Web:
www.mckimchiropractic.com
Email:
billing@mckimchiropractic.com
