Make a Payment Please fill out the form below in order to make a payment. Use the notes section if you have questions or concerns!Name(Required) First Last Phone(Required)Email(Required) Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Payment Amount(Required) Invoice # NotesMailing List Consent I would like to receive periodic emails and updates from Basal Therapies.Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name Get in touch! If you think your child could benefit from our support and services, send us a message! First Name* Last Name* Email Address* Phone Number* Concerns Following directions and answering questionsCommunicating (using gestures, words, etc.)Speaking clearly and being understoodMoving around safely/gross motor skillsPlaying with toysUsing their hands/fine motor skillsSensory concernsEmotional regulationHandwritingMental HealthFeedingOther (Explain below) Your Message Mailing List Consent I would like to receive periodic emails and updates from Basal Therapies.