Square Healthcare Forms

Securely collect medical data and fee payments online with Square and JotForm. Apply for a free unlimited HIPAA account today!

The first 100 payments every month are FREE.
Paid plans start as low as $29/mo
https://www.jotform.com
JotForm Square Payment Form
Full Name
My Products
Medical Mask
$10.00
Medical Glove
$10.00
Credit Card Information
Credit Card Number
Expiration Date
Security Code
Your payment is received with

All-in-One Medical Form Builder

Create HIPAA-compliant online forms to collect health data, schedule appointments, receive informed consent, conduct surveys, collect bill payments, and more.

Build Your Medical Form

Build Your Medical Form

Use our drag-and-drop Form Builder to create a HIPAA-compliant form for your healthcare practice.

Add Square

Add Square

Select Square from the list of payment gateways and connect your Square account.

Treat More Patients Faster

Treat More Patients Faster

Start collecting important patient information and payments online!

Secure Medical Payments

Accept Bill Payments with No Extra Fees

JotForm never charges additional transaction fees for collecting money through your forms. You just have to pay the standard Square rate.

Podo

Put patients over paperwork with Square, the payment gateway trusted by healthcare businesses around the world. By making it easier to accept online payments for medical treatments and prescriptions, Square takes care of business for you and keeps your practice HIPAA compliant — so you can focus on connecting with and treating your patients.

When you integrate Square with JotForm, your healthcare organization can seamlessly process medical payments online, without paying JotForm any additional transaction fees. And if you’re worried about protecting patients’ payment data online, both JotForm and Square offer PCI compliance — keeping your online transactions safe and secure.

To create a HIPAA-compliant online form for your organization, choose one of our free form templates or build a form from scratch. Then embed the form in your website, share it with a link, or fill it out directly on any device. Be sure to add HIPAA compliance by upgrading to a Silver or Gold plan and signing a Business Associate Agreement (BAA) — or if you’re switching to telemedicine in response to the COVID-19 pandemic, apply for a free unlimited HIPAA plan with our Coronavirus Responder Program.

This Dentist Uses JotForm & Square to Get Paid Quickly

User Spotlights

This Dentist Uses JotForm & Square to Get Paid Quickly

Dr. Cynthia Brattesani owns a top dentistry office in San Francisco. To keep her practice running, she needs to get paid. She used to collect payments through paper statements, but knew there had to be a better way. That’s when she started using JotForm and Square.

Build Your Own Payment Form

Create an account and start receiving payments!