ENCRYPTED ONLINE CREDIT CARD PAYMENT
Secure Server Enabled - ALL DATA IS REQUIRED AND MUST BE FILLED IN
-- Patient Information --
Patient's First Name
Patient's Last Name
Enter 5 Digit Number After Patient's Name on Statement
-- Credit Card Information --
Full Name as it Appears on Credit Card
Type of Credit Card (Visa, MasterCard, American Express)
Billing Name
Billing Address
Billing City, State ZIP
Phone Number
Credit Card Number
Credit Card Expiration date
Total dollar amount being charged to the account
Credit Card Verification/Authorization Number
[What is the Credit Card Verification/Authorization Number?]
ALL DATA IS REQUIRED AND MUST BE FILLED IN
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