Initial Consultation Payment Form – Houston Neuropsychology Associates

This form may be used to submit payment for an initial consultation. The fee will be applied toward the total cost of the evaluation in the event that further assessment is recommended. Please use this form only if we sent you a link to this page. If you’re looking for our general payment form, please click here.

Payor's Name(Required)

Please enter the name of the person making this payment.

First Middle Last

Are you making this payment on behalf of someone else?(Required)

Yes

Name of Beneficiary(Required)

Please enter the name of the person on whose behalf this payment will be made.

First Middle Last

Email for Receipt(Required)

Please enter the email address to which you would like your receipt sent.

Enter Email Confirm Email

Initial Consultation

Price:

Total

Credit Card(Required)

Card Details

Cardholder Name