Corsentino Chiropractic
Jenifer Leber
3501 Montlimar Plaza Dr
Mobile, AL 36609
(251) 445-2295
Secure Online Payments
Payment Information
Payment Amount
Contact / Shipping
First Name
*
Last Name
*
Email
*
Address
*
City
*
State
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
IT
VI
GU
PW
PR
MP
AS
AA
AP
AE
US
AB
BC
MB
NB
NF
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Zip
*
Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegowina
Botswana
Bouvet IS
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Canada
Cambodia
Cameroon
Cape Verde
Cayman ISS
Central African Republic
Chad
Chile
China
Christmas IS
Cocos (Keeling) ISS
Colombia
Comoros
Congo
Congo
Cook ISS
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland ISS (Malvinas)
Faroe ISS
Fiji
Finland
France
France
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald ISS
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Korea
Kuwait
Kyrgyzstan
Lao
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall ISS
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk IS
Northern Mariana ISS
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts & Nevis
St. Lucia
St. Vincent & Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon ISS
Somalia
South Africa
South Georgia
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
Sudan
Suriname
Svalbard & Jan Mayen ISS
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos ISS
Tuvalu
United States
United Kingdom
United States Minor Outlying ISS
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin ISS (British)
Virgin ISS (U.S.)
Wallis & Futuna ISS
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Phone
*
Billing Address
Copy Contact
Copy Contact Address
Billing Address
*
Billing City
*
Billing State
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
IT
VI
GU
PW
PR
MP
AS
AA
AP
AE
US
AB
BC
MB
NB
NF
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Billing Zip
*
Billing Country
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegowina
Botswana
Bouvet IS
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Canada
Cambodia
Cameroon
Cape Verde
Cayman ISS
Central African Republic
Chad
Chile
China
Christmas IS
Cocos (Keeling) ISS
Colombia
Comoros
Congo
Congo
Cook ISS
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland ISS (Malvinas)
Faroe ISS
Fiji
Finland
France
France
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald ISS
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Korea
Kuwait
Kyrgyzstan
Lao
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall ISS
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk IS
Northern Mariana ISS
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts & Nevis
St. Lucia
St. Vincent & Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon ISS
Somalia
South Africa
South Georgia
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
Sudan
Suriname
Svalbard & Jan Mayen ISS
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos ISS
Tuvalu
United States
United Kingdom
United States Minor Outlying ISS
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin ISS (British)
Virgin ISS (U.S.)
Wallis & Futuna ISS
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Billing
Billing Type
*
Select Billing Type
Credit/Debit Card
Bank Account (eCheck)
Name On Card
*
Credit Card Number
*
Card Expiration Date
*
MM
01
02
03
04
05
06
07
08
09
10
11
12
/
YYYY
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Card Verification Code
*
what's this?
First Name on Account
*
Last Name on Account
*
Bank Name
*
Routing Number
*
what's this?
Verify Routing Number
*
Account Number
*
Verify Account Number
*
*
Required
I affirm that the information entered on this form is true and correct.
Submit Payment
Privacy Policy
Corsentino Chiropractic
3501 Montlimar Plaza Dr Mobile, AL 36609
(251) 445-2295
To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.
Powered by Cash Practice® Systems