Thank you for taking advantage of our Online Payment service. Please allow up to 48 business hours for the payment to appear on your account. Patient Name* First Last Patient Number Patient DOB* MM slash DD slash YYYY Email to send payment receipt Bill Total* Service Charge Price: $0.00 Payment InformationCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Payment Total $0.00 * I acknowledge that a 3% service fee has been added to my online payment. Δ
