Payment Forms

React Bootstrap 5 Payment Forms 

Responsive React Payment Forms built with the latest Bootstrap 5. Credit card, PayPal, Stripe, eCommerce checkout, multi-step payment, donation form & more examples.

Basic example

Multi-step checkout template with discount details, order details, tax information and credit card form with switchable option.

Eligible

Pay
Cancel and return to the website
$85.00
Diabites Pump & Supplies
Insurance Responsibility
$71.76
Add Insurer card

Insurance claim and all neccessary dependencies will be submitted to your insurer for the covered portion of this order.

Aetna - Open Access Aetna - OAP
Patient Balance
$13.24
Add Payment card

Insurance claim and all neccessary dependencies will be submitted to your insurer for the covered portion of this order.

Proceed to payment
Order Recap
contracted Price $186.86
Amount Deductible $0.0
Coinsurance(0%) + $0.0
Copayment + 40.00
Total Deductible,
Coinsurance and copay $40.00
Maximum out-of-pocket
on insurance policy $40.00
Insurance Responsibility $71.76
Patient Balance $13.24
Total $85.00
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Ecommerce checkout page

A variation of a checkout page template - using radio buttons for debit card choice, and highlighting crucial payment information with different typography and icons.

ELIGIBLE |
Pay

$85.00

Diabetes Pump & Supplies

Insurance Responsibility $71.76

Add insurance card

Insurance claims and all necessary dependencies will be submitted to your insurer for the coverred portion of this order

Aetna-Open Access
OAP

Patient Balance $13.24

Add payment card

This is an estimate for the portion of your order (not covered by insurance) due today . once insurance finalizes their review refunds and/or balances will reconcile automatically.

Cancel and return to website

Order Recap

Contracted Price
$186.76
Amount toward deductible
$0.00
Coinsurance( 0% )
+ $0.00
Copayment
+ $40.00
Total Deductible, Coinsurance, and Copay
$40.00
Maximum out-of-pocket on Insurance Policy (not reached)
$6500.00
Insurance Responsibility
$71.76
Patient Balance
$71.76
Total
$85.00
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Payment card / Donation form

A simple payment form with credit card number and basic dollar amount input for customized amounts of payments / donations.

Martina Thomas**** 8880

Total amount due

$8245

Other amount

$
Go back
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Pricing plan with credit card payment details

Upgrade payment form with basic pricing plan card and a credit card form input.

Upgrade your plan

Please make the payment to start enjoying all the features of our premium plan as soon as possible

Small Business CHANGE PLAN
$ 8,350 / year

Payment details

Credit Card 1234 XXXX XXXX 2570
Credit Card 2344 XXXX XXXX 8880
ADD PAYMENT METHOD
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Credit card payment form

Simplistic card details payment step. This template is ideal if you have your shopping cart on a separate page.

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Credit card payment settings form template

Credit card configuration panel with an option to save your credit card numbers.

Settings

Payment
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Payment form

Payment form as a product card, it's possible to integrate this form with an eCommerce gallery.

Black Chair

Retro Chair

$760

Your payment details

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