BusinessName.com

 

Online Payment Page!

 

Yes, you can make a payment to an account "online" using you credit card and our payment form below.  Online credit card payments will be posted to your account within one business day.  You may also call us and we can process your credit card over the phone.

Your privacy is very important to us!  Therefore, to protect the confidentiality of the users of our site, all of the data that you type into one of our  "online" forms is encrypted before it leaves your computer and is not decrypted until it reaches our office.

	PATIENT INFORMATION
	Date:
	Patient's Name:
	Patient's Account Number (Optional):
	CARD HOLDER INFORMATION
	Name (As it appears on card):
	Card Type: _ Visa Mastercard American Express Discover
	Card Number:
	Expiration Date:
	Security Code*:
	* For Visa, MasterCard & Discover - Last three digits on back of card.  For American Express - four digits on front of card above card number.
	Card Holder Street Address:
	Card Holder Zip:
	Amount you wish to charge$: $
	Would you like a receipt mailed to the above address? Yes No
	Additional questions/concerns that you have:
	In an effort to be GREEN, please use the "Submit" button to send your payment directly to us.
	Image Verification Please enter the text from the image [ Refresh Image ] [ What's This? ]
	Thank you for your payment!