Online Bill Pay

Payment and Billing Information: Please fill out the necessary information affiliated with your payment type

PAYMENT SECURITY: To fully protect your payment information, we do not use a third party payment processor. After you enter it, your payment information is held on our encrypted server (we don't transfer ot to anyone - it never leaves our server). Our front desk staff then logs in and manually transfers your payment information directly into our credit card terminal right here in our office (just as if you were paying it right here personally). After your payment is processsed, we delete your payment information from our server. We do not retain any patient payment information in your account file

PAYMENT INFORMATION: You will not receive an online payment verification after entering your information. If you would like us to send you a payment verification via email, please include your email address in the Notes/Comments box at the bottom.

Visa
Master Card

Name on Card:
Card Number*:
Expiration Date:
Security Code *:
Amount *:
Address:
City:
State:
Zipcode:
Account/Family Number:

Notes / Comments: