Select Page
  • Patient #1

  • Patient #2

  • Patient #3

  • Billing Information

    This information is required
  • $0.00


  • To receive receipt via text please provide number

Payment Instructions

• For up to 3 patients:

  1. Enter your account # (V#)
  2. Enter full patient name
  3. Enter billing amount

• Enter billing address

• Enter credit card information

• Click Submit payment