Patient Payment Reminder Signup Form
Sign up to receive payment reminders and billing follow-up from your provider's office. Complete the required information below.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method for Payment Reminders
*
Email
Text Message (SMS)
Both Email and SMS
Best Time of Day to Receive Reminders
Please Select
Morning (8am - 12pm)
Afternoon (12pm - 5pm)
Evening (5pm - 9pm)
No Preference
Additional Comments (optional)
Submit
Should be Empty: