Payment Agreement Form Template

Make the payments process as convenient as possible with the Patient Payment Agreement PDF form. This template helps you gather all the necessary contact data, such as name, phone, and address. Using this simple payment agreement form, patients can also choose to pay in full or in instalments and enter their billing information for quick and convenient payment for services.

Design & Personalize

Use this free template and customize your Agreement Forms anyway you like. With MightyForms’ drag & drop editor, you can easily add, edit and delete a variety of fields. Include your logo and the colors and theme of your choosing. Any edit you make to the theme of the form is saved to your account, so you can use it on other forms. Add a personalized pop-up or confirmation e-mail to your respondents.

Publish & Integrate

Publish your Agreement Forms with a click of a button. Just copy and paste the code to embed it on a website, send it to an email list or share it over social media. You can integrate your Agreement Forms with Google Tag Manager and Google Analytics, that way you can more easily keep track of how well it is performing. You can also integrate your form with thousands of apps through Zapier.

Collect & Share

Keep track of real-time results and views of your forms right on your MightyForms account. Our templates are 100% responsive, so your respondents can fill out your Agreement Forms from any device. Edit existing entries and download the reports anytime. You can also customize notification emails to be sent to you and members of your team, optimizing your workflow and keeping everyone on the same page.

Add a date/time preference option

The time selection field won't take long to set up, but can be a great help in optimizing your workflow. Enable your users to set their preferred date and time for the appointment onsite by equipping your form with the appropriate section.

Expand functionality with ratings

Give your form extra interactivity and collect additional data by including a rating field in the template. Customize it however you want, modifying the number of pitches or changing the design of the icons, and allow your applicants to leave evaluations of their experience directly on the forms.

Enable e-signature field

Finally, you can augment your template with a handy e-signature field that would ask the applicant to leave their electronic signature, or provide the name of the supervising pilot. Setting up the e-signature option takes nothing more than a few clicks, but will definitely be useful if you prefer to keep all the details in one place

Continuous Capture

Тrack each form’s performance and make adjustments anytime. Ensuring data capture as the form is being populated — no matter if it gets submitted or abandoned afterwards, — the Continuous Capture feature allows you to pinpoint the fields with the highest drop-off rate, send form data straight to your Integrations, and automatically reach out to users that that quit filling to achieve the best possible results.

Catch leaving leads with Notifications or SMS

In just a few clicks, you can set up instant SMS/email alerts on submitted or abandoned forms to keep your eye on the ball. Merely add a notification content, be it a welcome message or a reminder of unfinished fields, select a recipient by specifying your team member, sender, or your own email, and you're ready to go.

Save & Resume

Make it possible for your respondents to get back to completing the form right from the point where they left off. Just tick the Save & Resume checkbox in Edit Form view, and your users can save the generated code to resume the submission at any convenient time.

Frequently asked questions

Nope, not a single line. All you have to do is drag and drop the required elements into your workspace using the wieldy MightForms editor, populate the fields with engaging content, and throw in an image or two for good measure. That's how your beautiful form comes into being in a matter of minutes.
Sure! MightyForms offers an unlimited selection of template customization tools to accommodate any goal and taste. Once you’ve chosen a suitable option from our plentiful template catalog, you can easily modify its fonts and colors, upload custom images, rearrange elements as you see fit, and even add your company logo for a professional touch.
Absolutely! After you finish editing the template and have it published, you will be presented with generated embed code that you can easily copy and paste wherever you want your form to appear. Alternatively, you can easily share your form using the ready-made shortcode, or simply by hitting the Share button.
Yes! Being armed with the plethora of integrations supported by the MightyForms builder, you can seamlessly connect your great forms to your favorite web applications, such as Google Sheets, WordPress, or MailChimp, and transfer data with no effort at all.
As of right now, for payment forms we're using Stripe to capture sensitive information such as credit card details. MightyForms doesn't record and store credit card data on it's side.

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