CLIENT PAYMENT FORM

CLIENT INFORMATION

PAYMENT OPTIONS

Please select a primary payment method:
Please select the preferred method of payment for any and all Patient Responsibility portion of your session balance:

CREDIT/DEBIT CARD INFORMATION

Type of Card:
Address of Cardholder
Address of Cardholder
City
State/Province
Zip/Postal

INSURANCE INFORMATION

Upload a picture of the front and back of your insurance card:
Maximum upload size: 10MB
Sending

*NOTE: Neither this form or any credit card information is stored on Revive’s website.  All forms are transmitted to Revive’s billing department and then immediately deleted.