Pay Form Fees – Children First Pediatrics

Form Fee Payments

This online bill pay should be used ONLY for paying for school/camp forms or medical record. If you are paying a balance you should now do so through the patient portal. DO NOT PAY BALANCES ON THIS SITE ANY LONGER

Please enter the amount in decimal format. If paying an even amount please enter as follows for example (20.00 and NOT 20 but DO NOT use symbols)
Please make sure your pop up blocker is turned off for this site PRIOR to submitting payment or the receipt confirmation will NOT send.
In addition to the receipt confirmation you should receive an email confirmation within a few minutes of submitting your payment request. Please make sure you enter the amount of the payment in the first field and the patient name and REASON for the payment in the second field.

Enter Amount *
Enter Patient Name & reason for payment(50 Char Max)* (Do not use any of special characters in this field or you will receive an error message ie: dashes, colons, semi-colons, commas, etc.)