Create an Online Payment Button (that collects Patient details)

This article will guide Modernizing Medicine merchants on how to add a Payment Button to your website.


I- Create Shop

II- Update the Shop Fields

III- Copy and Adjust HTML Template

I- Create the Shop

When adding online payments to your website it is best to create a separate Hosted Payments Shop
  1. Log into PayJunction as an administrator
  2. Select MoreHosted Payments from the left side menu:
  3. Click the New Shop button in the top right corner of this page:
  4. Fill out the form as shown below, replacing the values as necessary:
    - For the SHOP NAME, we recommend "Online_" followed by the name or initial of your business (Note: underscores are used instead of spaces). That will later make the reports self explanatory. 
    - If you have multiple accounts/batches, select the appropriate one from the ACCOUNT dropdown.
    - You can leave the EMAIL NEW ORDERS TO field blank if you want the notifications sent to the default email on the account. Otherwise you can have up to 3 emails separated by commas.
    - In the Security section, for the CAPTCHA VERIFICATION field, please select "On After Decline".
    - Click on CREATE SHOP to confirm and save your Hosted Payment.

II- Update the Shop Fields

After saving the new Shop you should be dropped back at the Shop page with your new Shop listed. Hover your mouse over the eye-icon for the shop and choose Shop Fields from the menu:


Use the Hide All shortcuts for each section and then make the following fields available as follow:  

  • NOTES (under Transaction Fields): Display
  • FIRST NAME (under Billing Contact): Required
  • LAST NAME (under Billing Contact): Required
  • ZIP CODE (under Billing Contact): Required

All fields in the Shipping Contact Fields should remain hidden.

Click  Save Changes to apply your updates. 

III- Copy and Adjust HTML Template

Once you have your Hosted Payments Shop Name, follow these steps:

  1. Highlight all of the HTML code that is listed within the text area below.
  2. Copy the HTML.
  3. Paste the code on your web page.
  4. Update the description field with the name of your business
  5. Update the Store field with your Hosted Payment Shop Name. 
  6. Save your webpage, and test the payment button.
<form method="post" action="" >
<input type="hidden" name="description" value="Name of your Business">
<input type="hidden" name="need_to_ship" value="no">
<input type="hidden" name="need_to_tax" value="no">
<input type="hidden" name="identifier" value="Online Payment">
<input type="hidden" name="quantity" value="1">
<input type="hidden" name="store" value="YOUR-HOSTED-PAYMENTS-SHOP-NAME">
<input type="hidden" name="notes" value="" id="notes">
<table style="width:80%">
<td><label>Patient First Name: (<font color="red">*</font>)</label></td>
<td><input type="text" required name="shippingFirstName" id="shippingFirstName"></td>
<td><label>Patient Last Name: (<font color="red">*</font>)</label></td>
<td><input type="text" required name="shippingLastName" id="shippingLastName"></td>
<td><label>Patient DOB: (<font color="red">*</font>)</label> </td>
<td><input type="text" required name="notes" id="patientDOB"></td>
<td><label>Patient ID Number:</label> </td>
<td><input type="text" name="billingCustomerId" id="billingCustomerId"></td>
<td><label>Payment amount $: (<font color="red">*</font>)</label></td>
<td><input type="text" name="price"></td>
<td align="left">
<input type="submit" name="submit" value="Proceed to Payment" onclick="concatenateNotes()">
(<font color="red">*</font>): Mandatory Fields
<script type="text/javascript">
function concatenateNotes()
document.getElementById('notes').value = 'Patient First Name: ' + document.getElementById('shippingFirstName').value
+ '\n' + 'Patient last Name: ' +
+ '\n' + 'Patient DOB: ' +
+ '\n' + 'Patient ID: ' +


The form will looks something like this. Your Styling may change the looks and you can style the form to match your site as long as the form works properly.