Use our readymade template to create this Google form. Customize it further using our form builder.
Create your payment form
- Use prebuilt template to create a secure online payment form
- Collect patient details, including name, gender, date of birth, contact information
- Collect payment details, including amount due, description of illness or injury
- Collect additional information, such as doctor's notes, place of service
- Ensure compliance with payment card industry data security standards (PCI DSS)
Collect payments from your patients
| Patient ID | user input |
| Patient Name | John Doe |
| Gender | Male |
| Date of Birth | 1985-06-15 |
| Patient Phone Number | user input |
| Patient Email | user input |
| Patient Address | user input |
| Date of service | 2023-08-08 |
| Place of service | user input |
| Description of illness or injury | user input |
| Doctor's notes | user input |
| Amount Due | user input |
- Integrate with popular payment gateways to securely process patient payments
- Accept credit card payments, debit card payments, and other forms of electronic payments
- Provide patients with a seamless payment experience on any device
- Automatically calculate the total amount due based on the services provided
- Send payment confirmation emails to patients after successful transactions
Track payment records in Google Sheets
- Export payment records to Google Sheets for easy record-keeping and analysis
- Create custom reports to track payment trends and analyze revenue streams
- Automatically update payment records in real-time as patients make payments
- Send payment receipts to patients via email with a copy of their payment details
- Use data in Google Sheets to integrate with accounting systems for streamlined financial management
Secure and compliant
| Patient ID: | user input |
| Patient Name: | John Doe |
| Gender: | Male |
| Date of Birth: | 6/15/1985 |
| Patient Phone Number: | user input |
| Patient Email: | user input |
| Patient Address: | user input |
| Date of service: | 8/8/2023 |
| Place of service: | user input |
| Description of illness or injury: | user input |
| Doctor's notes: | user input |
| Amount Due: | user input |
- Ensure the security of patient payment data with encryption and secure data storage
- Comply with payment card industry data security standards (PCI DSS)
- Implement measures to prevent unauthorized access to patient payment information
- Regularly update and maintain security protocols to protect against data breaches
- Provide peace of mind to patients by safeguarding their payment information
These reviews are reproduced without modification from Google Workspace Marketplace.
May 30, 2025
Besides the fact that one gets billed $216 monthly, Support took a long time to try and get things to work. Trying to get things signed on a form was such an issue and through out formatting. Way over priced, support that you have to wait till the next day to get one thing sorted and not sorted, back and forth the whole time. Frustrating customers and damage to business. I will not reccommend this company to anyone. Try JotForms so much better, and you can do much more for a fraction of the cost per year not per month.
— Francois Ohsiek
June 3, 2025
Hi Francois, sorry you had a frustrating experience with the formatting. Just to clarify, the plan you’re on is $216 per year, not per month. You signed up for the Formesign Esignature paid plan on May 8, 2024, and since you also needed to sign agreements, we provided access to our Formesign - Fillable PDF add-on at no extra cost. Regarding formatting: when working with Google Docs templates, we recommend using lists instead of indents and setting up layouts with tables for images, rather than inserting images directly. This helps maintain proper formatting. To assist, we also created and shared a sample template as a reference. You had asked us to make edits on your behalf, which we’re not able to do for security reasons. However, we did reach out and invited you to join a scheduled Zoom call to walk through the process — as we’ve done several times over the past year — but we didn’t receive a response. Update: To make things easier for all users, we have just launched the new document editor in Formesign that will allow agreements to be created directly, without relying on Google Docs.
— Formfacade
July 23, 2023
I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!
— Sol Evans
July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
February 16, 2024
Does not work
— Myles Sicuro
November 27, 2023
Yeah this is good for all
— luqman Khan
July 10, 2023
We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.
— Joan S