Pneuma Center - Online Payment Form

Sharon Roberts, B.A.

Lon
Roberts, Ph.D.

Call for Information
972-985-1731

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Updated 9/15/13}

Payment Form for Officiating
Life Celebration Services
and Baby Welcoming Ceremonies

Payment by credit card is a simple two-part process to ensure maximum security:

First, complete the form below, then press the "Submit Form" button. This will cause the Confirmation page to appear.
On the Confirmation page, select the amount of the payment then press the "Make Payment" button to complete the secure transaction.

Note: If you haven't done so already, please contact us to ensure we are availability on the desired date and time. You can contact us by e-mail or by phone at 972-985-1731.

Which of our services does this payment apply to?

Officiate a Life Celebration Service
Officiate a Baby Welcoming/Naming Ceremony
Grief Counseling
Other (specify in the box below)

What do you wish to pay for at this time?

Deposit (Note: The deposit is a partial payment that will be applied to the total due.)
Remaining balance (after the deposit)
Payment in full
Other (specify in the box below)

Please provide the following information:

Your Name:

E-mail:

Phone:

Date of the Service, Ceremony or Session: Time:

Location:

For validation, enter the numbers here in this box:

After you have entered the information, press the Submit Form button below. This will send you to a Confirmation Page to enter the amount of the payment, after which you will be directed to a secure site to enter your credit card information.

Pneuma Center
Concord, NH
Phone: 603-230-2422
Email: info@pneumacenter.com