One Time Credit Card Payment

Doctor/Therapist Name*
Hidden
Doctor/Therapist Name
First Last
Card Holder's Name:*
First Last
Amount to be paid:*
Patient Name:*
First Last
Patient Account Number:
Credit Card #:*
Please include spaces in the number as shown on card. For example 1234-5678-9111-0000
Expiration Date*
Is Your Card an American Express?*
- Yes
- No
Four numbers on front for American Express (if applicable)*
Three numbers on back of card:*
Card Holder Phone #:*
Card Holder Email:*
Address:*
Street Address Address Line 2 City State ZIP Code
By signing below, I hereby authorize the provider listed above or designated staff to bill my credit card for services rendered.
Date:*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.