Payments

Please use our form below to make credit card payments on any balance that you may have due. Please pay a minimum of $50 per payment unless you are paying off a remaining balance of less than $50. Thanks!

Patient Account #*
Please enter your patient account or invoice number here.
Patient Name*
First Last
Is the billing Credit/ Debit card under the patient's name or another name?*
- Patient
- Other
Name of Cardholder (will need to be asked for below as well)*
First Last
Email to Send Payment Confirmation*
Enter Email Confirm Email
Enter Amount to be Paid*

Please input the amount of your balance that you are paying at this time. Must be a minimum $50 if not paying off remaining balance less than $50.
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Confirmed Total
$0.00
Credit Card*

Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

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