Pay online

Thank you for trying our new online payment option for Post Rock Family Medicine! If you experience any problem using this feature, please email or call us at (785) 434-2622 and ask for online payment support staff.

[stripe_form_section_row label=”Statement Account Number (?)” input=”“]
[stripe_form_section_row label=”Email Address (?)” input=”“]
[stripe_form_section_row label=”Phone number (?)” input=”“]
[stripe_form_section_row label=”Cardholder’s First Name (?)” input=”“]
[stripe_form_section_row label=”Cardholder’s Last Name (?)” input=”“]

Thank You, {fname} {lname}

$ {amount} will be posted to account {acctnum}.

A receipt has been sent to {email}.

Transaction ID: {id}