Step 1. Enter Payment Information
Patient Account Information
*
Required
*
Patient First Name
M.I.
*
Patient Last Name
Patient Account #
*
Date of Birth
Telephone Number
Email Address
Comments
Credit Card Information
First Name
Last Name
Street Address
Address 2 (suite, unit, apt)
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
Discover
American Express
Credit Card Number
Expiration (mm/yy)
01
02
03
04
05
06
07
08
09
10
11
12
/
24
25
26
27
28
29
30
31
32
CVV
(3 or 4 digit security code)
AMOUNT
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