Park Central's Payment Form

This form is for your convenience. If you have a balance and need to put something toward it, visit your patient portal and select "View Statement" to download your most current balance. Should you have any questions about your balance, please contact the billing department at the number listed on the bill.
Patient Name *

First Name Last Name
Payment *

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USD $10.00 minimum. You will be redirected to PayPal for all electronic payment types.
What I'm paying for *
Best Contact Number *
Patient E-Mail *
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Enter the message as it's shown *
Date

Month Day Year
Date Hour Minutes AM/PM Option
Should be Empty: