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     Zip Code 
Credit Card Type 
*Credit Card Number 
*Expiration Date 
 /  (mm/yy)
*Credit Card CCV  (3 or 4 digit security code)
*Payment Amount $