Financial Details Submission

Please use this form to securely submit your bank or credit card details.

You can choose to give us both credit card and bank account details or just one. If you have preferences of using either one any particular month, just let us know in advance.

Important Security Note:

This form collects sensitive financial information. For your security and peace of mind, we strongly encourage you to contact Arun Mallikarjunan privately to verify this request if you have any concerns before proceeding.

Clinic & Contact Information

Clinic Name *

Primary Contact Email *

Bank Account Details (for ACH Payments)

Bank Name

Bank Account Number

Confirm Bank Account Number

Bank account numbers do not match.

Bank Routing Number

Credit Card Details

Name on Credit Card

Credit Card Number

Invalid credit card number.

Expiry Month

Expiry Year

CVV/CVC

Zipcode

Please Note:

A 3% processing fee applies to credit card payments for amounts exceeding $1000.

I give permission to Practice in a box, Inc to charge my bank or card for their services. My payment details will be stored in my profile and will only be used for approved purchases.

Please print your name to agree to the terms above.*

Please print your name to agree.