Payment Form

Please enable JavaScript in your browser to complete this form.

Patient Name *

First

Last

Cardholder Name *

First

Last

Email *

Card Number *

Credit Card numbers are not saved or kept on file

Expiration MMYY *

CVV 3-Digit Security Code *

Billing Address: House #, Street, City, State, Zip *

Payment Type *

Payment Amount *

Please specify the amount you authorize Pediatric Sensory Therapy to charge on the above card.

Comments

-We are hiring SLP, OT & COTA! Please email us your resume!

-Our SLP department is open and accepting new patients.

Can’t reach us at the office, call or text our cell!

503-877-4177