Patient Information

*Patient Name:

*Account Number or Visit ID:

*Patient DOB:

MM/DD/YYYY

*Amount to Pay: $

Debit / Credit / HSA Card Information

*Card Number:

*Expiration Date:

* CVV2:

What is this?

-OR- Checking Account Information

*Account Type:

*Routing Number:

*Account Number:

*Repeat Account Number:

*I Agree:

I am authorized on the above account and agree to have the account debited today for the specified amount. I am responsible for any NSF fees due to insufficient funds.

* Signed:

Billing Information

*First Name:

*Last Name:

*Billing Address:

*Billing Zip Code:

*Email Address:

Due to credit processing costs, a 3% surcharge will be applied to credit card transactions