Make a Payment

For your convenience, Granite Wellness Centers offers online payments. You can use this payment form to pay for services for yourself or on behalf of a loved one.

"*" indicates required fields

Patient Name*

First Last

Name of the person receiving services.

Patient Date of Birth*

Your Name*

First Last

Relationship to Patient*

Your Email Address*

Address*

Street Address City State ZIP Code

Phone Number*

Type of services you are paying for.*

Please list the service you are issuing a payment for: Outpatient, Residential, Detox, Transitional Living, DUI, etc.

Service you are paying for*

Residential*

Out Patient Client*

Payment Amount*

Credit Card*

Card Details

Cardholder Name

60846