Form for Paying by Credit Card or Check

If you wish to pay your bill by credit card or check, fill out the following form and press the "Submit" button when you're finished. Please be aware that all information must be included to process your payment successfully. Thank you!

Patient Information
Name:
Required
Account:
Required
Billing Information
First Name:
Required
Middle Name:
Last Name:
Required
 
(as it appears on credit card or check)
 
Country:
Required
Address:
Required
Address 2:
City:
Required
State/Province:
Required
Zip/Postal Code:
Required
Day Phone:

--

Required
E-Mail:
Required
Payment Amount:
$ Required
Select a Billing Method
Please select an option from the list below.
Pay by Credit Card

Pay by Check