Online Payment Form Questionnaire Santa Rosa CA, PBHS

PBHS Basic Online Payment Form Setup

Step 1 of 5

Please include your basic practice information below (this is used for PBHS Support to contact you or the office directly):
Your Name*
Your Practice Name*
Your Contact E-mail Address*
PBHS Support will use this email address to communicate with you regarding this order.
Your Phone Number*
Website URL*
(ex. http://www.drjohnsmithdds.com/)

Your website's online payment form is compatible with either an existing PayPal account an existing Authorize.net account. , or an existing Stripe account.

Once the payment form is setup, the patient will enter their basic information and complete the transaction securely and conveniently. Our system will notify you when new payments are submitted, and transfer the total amount due, first/last name, address, and email filled out from your website right to your PayPal or Authorize.net account.
* For the PayPal setup - You must have an existing PayPal business/merchant account (if you need to create one you may need to sign up and pay for PayPal online services separately). Once the online payment form submitted by the patient, they will be directed to the PayPal website to complete the transaction. The patient may have an existing PayPal account (or create a account to pay their bill online which is free and easy to do) or they will also have the option to simply pay with a credit card. Once they submit their online payment, the patient/user will be auto directed right back to your website for further browsing!

* For the Authorize.net setup - You must have an existing Authorize.net business/merchant account (if you need to create one you may need to sign up and pay for Authorize.net online services separately). Once the online payment form submitted by the patient, we will transfer this information directly to Authorize.net for processing. The required SSL purchased with your Online Payment Form will ensure the safety of your patients information during this transfer!

Please select either PayPal, Authorize.net, or Stripe for your website online payment form:

PAYPAL ACCOUNT INFORMATION
*This information is used for initial setup of the payment form on your website, and is NOT recorded.*
I. Existing PayPal account?

If you already have your account setup through PayPal, please provide PBHS Support with the following information.
A. E-mail Address used for your PayPal account:*
B. We ask that you please verify that your PayPal account has the IPN setting enabled:

* Login to your PayPal account.
* Click Profile under the My Account tab.
* Click My selling tools. Click "Update" in the Instant payment notifications section. Click Choose IPN Settings to specify your URL and activate.
*The URL you enter should be as follows: http://www.YOURDOMAIN.com/?page=gf_paypal_ipn
Be sure to substitute your real domain name in the "YOURDOMAIN" portion above!
Please verify:*
- My IPN setting is now enabled.
II. Need to setup a new PayPal account?

You may follow the link provided below which will lead you to the free sign-up and further information about a PayPal Business standard Account:
● https://www.paypal.com/webapps/mpp/paypal-payments-standard
● Click the BLUE button labeled "Get Started"

Once your account is setup, please enter the information requested in part A and B above.
AUTHORIZE.NET ACCOUNT INFORMATION
*This information is used for initial setup of the payment form on your website, and is NOT recorded.*
You will need an existing Authorize.net account in order to proceed with the setup of the online payment form.

Within your Authorize.net account, please obtain:
API Login ID*
API Login ID You can find your unique API Login ID by clicking on the 'Account' link at the Authorize.Net Merchant Interface. Then click 'API Login ID and Transaction Key'. Your API Login ID will be displayed.
Your Transaction key*
You can find your unique Transaction Key by clicking on the 'Account' link at the Authorize.Net Merchant Interface. Then click 'API Login ID and Transaction Key'. For security reasons, you cannot view your Transaction Key, but you will be able to generate a new one.
For new accounts, follow the new account setup "walk through" that provides guidelines and steps for proper account setup.

We highly recommend contacting Authorize.net directly to assist you with obtaining the information above, they will be happy to assist you to ensure your account is setup properly.
You will need an existing Stripe account in order to proceed with the setup of the online payment form.

Please follow the instructions at the link below in order to add PBHS as an Admin to your Stripe account. This will be necessary in order to utilize our Payment Form with Stripe:
Adding PBHS To Your Stripe Account For Online Payment Forms
I have Added PBHS as an Admin to my Stripe Account*
- Check this box to certify that you have added PBHS as an Admin on your Stripe account.
Email Address*

Please enter the Email address associated with your Stripe account.

Where would you like this form placed on your website?

DEFAULT: By default we will create a new page on your website under the Patient Information tab called Online Payments.
For example: http://www.yourdomain.com/patient-information/online-payments/

OTHER: If you'd like to add this form in an alternate location on your site, please advise!
Where would you like the online payment form placed on your website?*
- Default placement

Thank you for taking the time to complete your Online Payment form setup questionnaire!

Please include any special notes or comments in the field below and click the "Submit Form" button to officially send this information to PBHS Support!
Comments/Questions
PBHS Support will contact you upon receipt of this setup information to move forward and add the online payment form to your website.
We will notify you if any further action is needed on your end presently!
Thank you!
Initials
This field is for validation purposes and should be left unchanged.

Online Payment Form Questionnaire

PBHS Basic Online Payment Form Setup

Step 1 of 5

Your website's online payment form is compatible with either an existing PayPal account an existing Authorize.net account. , or an existing Stripe account.

Where would you like this form placed on your website?

Thank you for taking the time to complete your Online Payment form setup questionnaire!