Payment Form

The Luminous Mind
1611 County Rd B W, ste 202 | Roseville, MN 55113
Phone 651.300.1112 | Fax 651.358.2996

Client Name*

First NameLast Name

Payer's Email Address*

example@example.com

Payer's Phone Number*

Please enter a valid phone number.

I would like to pay the following amount:*

USDEnter total of payment you would like to make

Credit Card Information

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I certify that I am an authorized user of this credit card/HSA/debit card and will not dispute this transaction *

DateTime