MAKE A PAYMENT
2025 form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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Phone Number
*
text eligible best
E-mail
*
example@example.com
Invoice Number or payment for specific past date of service (optional)
This payment is for
Past amount due
Upcoming visit
Other
Payment
*
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next
( X )
USD
Amount (00.00)
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
CREDIT CARD
*
VISA
MASTERCARD
AMERICAN EXPRESS
DISCOVERY
Other
Whose credit card is this?
*
Patient
Legal Guardian
specify relation
Signature
*
Please sign your name in the space above. Tap to begin.
Date
-
Month
-
Day
Year
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One more agreement tab will appear after submission. Please complete it to finalize payment.
SUBMIT
SUBMIT
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