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 27, 2023
I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!
— Royal Bush
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
February 16, 2024
Does not work
— Myles Sicuro
October 31, 2023
We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!
— Chris Henesy
July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
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