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 smaddox@pvmc.us or call us at (785) 434-2622 and ask for online payment support staff.

[stripe_form_begin]
[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_amount]
[stripe_form_section_row label=”Cardholder’s First Name (?)” input=”“]
[stripe_form_section_row label=”Cardholder’s Last Name (?)” input=”“]
[stripe_form_payment_info]
[stripe_form_end]
[stripe_form_receipt]

Thank You, {fname} {lname}

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

A receipt has been sent to {email}.

Transaction ID: {id}

[/stripe_form_receipt]