Payment Form

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Patient Name *

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Last

Cardholder Name *

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Email *

Card Number *

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Expiration MMYY *

CVV 3-Digit Security Code *

Billing Address: House #, Street, City, State, Zip *

Payment Type *

Payment Amount *

Please specify the amount you authorize Pediatric Sensory Therapy to charge on the above card.

Comments

-We are hiring OT & COTA! Please email us your resume!

-Our SLP department is currently accepting new patients!

Can’t reach us at the office, call or text our cell!

503-877-4177