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Payment Agreement Form

Your contact and payment information is safe with us. We use Secure Site Licensing to encrypt and protect all data that is sent through our website. This form does not store payment or contact information to our web servers.

Please note:  At this time, we can only take payments 2 days from the current date. If you would like to schedule a payment plan for today’s date, contact us at (360) 286-0404 during business hours.


Use the calculations you received on the above form to setup your monthly payment plan with Peninsula Podiatry. We will contact you directly to confirm that your payment plan was accepted.

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