Allergy & Asthma Consultants Payment Page

SECURE PAYMENT PROCESSING PAGE

Your payment and personal information is always safe. Our card processor’s Secure Sockets Layer (SSL) software is the industry standard and among the best software available today for secure commerce transactions.

It encrypts all of your personal information, including credit card number, name, and address, so that it cannot be read over the internet.

All sections of this form must be completed to process payment.

Patient Name
This section is for the the Patient's information
Name*
First Last
Account Number (5-6 digits)*
Payment Amount*
Payment Information
This section is for the the Payer's information
Debit or Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Payment Amount
$0.00
hCaptcha*

SECURE PAYMENT PROCESSING PAGE

Patient Name

Payment Information