{"id":65,"date":"2026-02-06T20:08:43","date_gmt":"2026-02-06T20:08:43","guid":{"rendered":"https:\/\/novapainandrehab.com\/ads\/?page_id=65"},"modified":"2026-02-10T20:31:11","modified_gmt":"2026-02-10T20:31:11","slug":"cc-payment","status":"publish","type":"page","link":"https:\/\/novapainandrehab.com\/ads\/cc-payment\/","title":{"rendered":"CC Payment"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#004582&#8243; custom_padding=&#8221;14px||0px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;1_3,1_3,1_3&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;-17px|auto||auto||&#8221; custom_padding=&#8221;||26px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_3&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|600|||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; text_font_size=&#8221;40px&#8221; background_color=&#8221;RGBA(255,255,255,0)&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><em>Feel Better<\/em><\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_3&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|600|||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; text_font_size=&#8221;40px&#8221; background_color=&#8221;RGBA(255,255,255,0)&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><em>Get Stronger<\/em><\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_3&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|600|||||||&#8221; text_text_color=&#8221;#FFFFFF&#8221; text_font_size=&#8221;40px&#8221; background_color=&#8221;RGBA(255,255,255,0)&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><em>Heal Quicker<\/em><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_header _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; background_image=&#8221;https:\/\/novapainandrehab.com\/ads\/wp-content\/uploads\/2026\/02\/People-Header4-scaled.jpg&#8221; custom_padding=&#8221;||185px|||&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;-1px|||||&#8221; custom_padding=&#8221;82px||70px|||&#8221; top_divider_style=&#8221;arrow2&#8243; top_divider_color=&#8221;#024a84&#8243; top_divider_height=&#8221;75px&#8221; bottom_divider_style=&#8221;arrow2&#8243; bottom_divider_color=&#8221;#023e72&#8243; bottom_divider_height=&#8221;50px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;1px|auto|1px|auto|true|&#8221; custom_padding=&#8221;0px||0px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243; disabled_on=&#8221;off|on|on&#8221; custom_margin=&#8221;||9px|||&#8221;]<\/p>\n<h2 style=\"text-align: center;\"><strong><span style=\"color: #000000;\">New Patient Health &amp; Injury Assessment<\/span><\/strong><\/h2>\n<p style=\"text-align: center;\"><span style=\"color: #000000;\"><em><span style=\"font-size: xx-large;\">Make Your Payment<\/span><\/em><\/span><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font=&#8221;|700|||||||&#8221; text_text_color=&#8221;#023b6d&#8221; text_font_size=&#8221;45px&#8221; custom_padding=&#8221;16px|||||&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243; disabled_on=&#8221;on|off|off&#8221; custom_margin=&#8221;||24px|||&#8221;]<\/p>\n<p style=\"text-align: center;\">New Patient Health &amp; Injury Assessment<\/p>\n<p style=\"text-align: center;\"><em><span style=\"font-size: xx-large;\">Make Your Payment<\/span><\/em><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;18px&#8221; custom_padding=&#8221;20px|20px|20px|20px|false|false&#8221; box_shadow_style=&#8221;preset2&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><span style=\"color: #000000; font-size: large;\">Fill out the Credit Card payment form below, then press the Submit button to schedule your appointment:<\/span><\/p>\n<style id=\"wpforms-css-vars-58\">\n\t\t\t\t#wpforms-58 {\n\t\t\t\t--wpforms-container-padding: 0px;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-radius: 3px;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-58\"><form id=\"wpforms-form-58\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"58\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/ads\/wp-json\/wp\/v2\/pages\/65\" data-token=\"0e54b539aa881b0d52ef2eaf826dd3bd\" data-token-time=\"1776603315\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\">\t\t<div id=\"wpforms-58-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-58-field_7\" >Number Date (MM\/DD\/YYYY)<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-58-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-58-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_1\">Name on Card <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-58-field_1-error\" required><\/div><div id=\"wpforms-58-field_2-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_2\">Credit Card Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-58-field_2-error\" required><\/div><div id=\"wpforms-58-field_3-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_3\">Expiration Date (MM\/DD\/YYYY) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-58-field_3-error\" required><\/div><div id=\"wpforms-58-field_4-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_4\">Billing Zipcode <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-58-field_4-error\" required><\/div><div id=\"wpforms-58-field_5-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_5\">CCV# <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_5\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-58-field_5-error\" required><\/div><div id=\"wpforms-58-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_6\">Signature (type your name) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-58-field_6-error\" required><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-58-field_7-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-58-field_7-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-58-field_7-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6LcJugcqAAAAAPx_4H0TszmQmAIZfZiLcgyuD1Ca\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"58\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/novapainandrehab.com\/ads\/wp-json\/wp\/v2\/pages\/65\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-58\" class=\"wpforms-submit\" data-alt-text=\"Submitting...\" data-submit-text=\"Submit $49 Payment, then Schedule Appointment\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit $49 Payment, then Schedule Appointment<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/novapainandrehab.com\/ads\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.5&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;18px&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p style=\"text-align: center;\"><strong><span style=\"color: #000000;\">To learn more about what the NOVA Pain &amp; Rehab Center can do for you, <span style=\"text-decoration: underline;\"><a href=\"https:\/\/novapainandrehab.com\" target=\"_blank\" rel=\"noopener\">CLICK HERE<\/a><\/span>.<\/span><\/strong><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Feel BetterGet StrongerHeal QuickerNew Patient Health &amp; Injury Assessment Make Your PaymentNew Patient Health &amp; Injury Assessment Make Your PaymentFill out the Credit Card payment form below, then press the Submit button to schedule your appointment: <style id=\"wpforms-css-vars-58\">\n\t\t\t\t#wpforms-58 {\n\t\t\t\t--wpforms-container-padding: 0px;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-radius: 3px;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-58\"><form id=\"wpforms-form-58\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"58\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/ads\/wp-json\/wp\/v2\/pages\/65\" data-token=\"0e54b539aa881b0d52ef2eaf826dd3bd\" data-token-time=\"1776603315\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-58-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_1\">Name on Card <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-58-field_1-error\" required><\/div><div id=\"wpforms-58-field_2-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_2\">Credit Card Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-58-field_2-error\" required><\/div><div id=\"wpforms-58-field_3-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_3\">Expiration Date (MM\/DD\/YYYY) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-58-field_3-error\" required><\/div>\t\t<div id=\"wpforms-58-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-58-field_7\" >Zipcode Card Name<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-58-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-58-field_4-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_4\">Billing Zipcode <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-58-field_4-error\" required><\/div><div id=\"wpforms-58-field_5-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_5\">CCV# <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_5\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-58-field_5-error\" required><\/div><div id=\"wpforms-58-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_6\">Signature (type your name) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-58-field_6-error\" required><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-58-field_7-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-58-field_7-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-58-field_7-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6LcJugcqAAAAAPx_4H0TszmQmAIZfZiLcgyuD1Ca\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"58\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/novapainandrehab.com\/ads\/wp-json\/wp\/v2\/pages\/65\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-58\" class=\"wpforms-submit\" data-alt-text=\"Submitting...\" 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