Credit Card Authorization
This is a secure form and we will delete once completed
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
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Month
-
Day
Year
Date
State amount you are charging card here. Your card information is not stored following this transaction. Each time you make a transaction you will have to complete this form again.
*
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( X )
USD
Description
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Signature
*
Submit
Should be Empty: