Payment for Keys to Independence (Driving Program) In-Clinic Evaluation

Payment for Keys to Independence (Driving Program) In-Clinic Evaluation
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
The in-clinic evaluation is paid in two parts. We require a $150 deposit to hold your appointment. This goes towards your full fee. The remainder is to be charged on the day of evaluation.

Please Select One of the Following*

Deposit

paid prior to evaluation, to hold appointment

$150.00

Remainder of Payment

paid on the day of evaluation

$215.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country