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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
  • Payment Information

    This section is for the the Payer's information
  • American Express
    Discover
    MasterCard
    Visa
     
  • $0.00