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.
July 23, 2023
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October 31, 2023
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February 16, 2024
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July 12, 2023
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November 27, 2023
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July 10, 2023
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