Payment

Client Payment Portal

Payment Choice:(Required)

Add Funds to Patient Account

Payment Toward Invoice

Patient Name (first)(Required)

(Middle)

(Last)(Required)

Patient Date of Birth

Account Number

Found on Statement

Billing Address

Street Address Address Line 2 City State ZIP Code

Amount to Charge

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Total

Authorization(Required)

I certify that I am an authorized user of this debit/credit card and that I hereby authorize insert name of the company to charge my card in the amount indicated above.

Payment

Client Payment Portal

855-908-0047