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Online Patient Payment



Patient Account Information

Patient First Name:
Patient Last Name:
Date of Birth:
Payment Type:
Patient Number:
Phone Number:
Patient Address:
Patient City:
Patient State:    Zip:
Comments:

Credit Card Information

Payment Amount:
Credit Card:
Credit Card Number:
Expiration Date:   
Cardholder's Name:
Card ID Number:   (Required for your security)
What is this?

Credit Card Billing Address

Cardholder's Email:
The billing address is the same as the patient address.
Address:
City:
State:    Zip:



Click the button to go to the next screen.
Your credit card will not be charged until you click submit.

Online Patient Payment Info Review



Please review the information below to confirm its accuracy. Click the 'go back' button to make corrections to the information or click the 'finalize payment' button below to submit your payment.

Patient Account Information
Patient Name:
Date of Birth:
Payment Type:
Patient Number:
Phone Number:
Patient Address:
Patient City:
Patient State:     Zip: 
Comments:

Credit Card Information
Payment Amount:
Credit Card Type:
Credit Card Number:
Expiration Date:
Cardholder's Name:
Card ID Number:

Credit Card Billing Address
Cardholder's Email:
Address:
City:
State:     Zip: 

  

Online Patient Payment Complete



Payment Confirmed
Your payment has been sent. Please print this page for your records. You should get a payment confirmation email shortly.



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