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Cowtown Pediatrix Payment Options
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Patient name:
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Your answer
Accepted Forms of Payment:
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Cash
Check
HSA
Credit Card
Venmo
For venmo, fill out venmo information below. The office will request payment at time of therapy service. Please pay request within session time.
How to sign up: Download the Venmo App on your phone. The App will take you through the steps to set up your Venmo account. You can link it to your bank account or credit card.
Please check one
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I will pay with Venmo
I will pay with cash or check (due at time of service)
I will pay with HSA card / credit card
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If you are paying with Venmo, please list the Venmo account name you will be paying from.
Venmo account name (example @Cowtown-PediatrixClinic):
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Your answer
If you are paying with an HSA card / credit card, please fill out the following:
Name on the card:
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Your answer
Card number:
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Your answer
Expiration date:
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Your answer
3 or 4 digit number on the back of card:
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Your answer
Billing address zip code:
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Your answer
Today's Date:
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