Please fill in the following from your statement:

* Indicates a required field.

Your Patient Account Number
(including the initial 3 character code) *
Statement Date *

Please fill in the following payment information:

Amount You Are Paying (Enter Amount Only - no dollar sign, e.g. 25.00) *
Your Credit Card Number *
Expiration Date (MM/YY) * /
First Name (on card) *
Last Name (on card) *
Billing Address *
City *
State *
Zip Code *
 
Email Address (for receipt)