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Patient Name

First

Last

Relationship to the patient

Patient Payment Name

Phone

Patient's Date of Birth

Patient Account Number

Make a Payment

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Credit Card

Card Number

Expiration

Security Code

American Express Discover MasterCard Visa

Effective June 1st, 2024, we will be imposing a 2% surcharge on the transaction amount for all credit card payments.

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