Step 1. Enter Payment Information
PATIENT ACCOUNT INFORMATION
Fields marked with
*
are required.
*
Patient Name
Patient Account #
*
Date of Birth
Comments
*
Telephone Number
*
Email Address
CREDIT CARD INFORMATION
*
First Name
*
Last Name
*
Street Address
Address 2
*
City
*
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code
Credit Card Type
MasterCard
Visa
American Express
Discover
*
Credit Card Number
*
Expiration Date
01
02
03
04
05
06
07
08
09
10
11
12
/
21
22
23
24
25
26
27
28
29
30
(mm/yy)
*
Credit Card CCV
(3 or 4 digit security code)
*
Payment Amount $