Payments

Patient Name:
Date of Birth:
Location:
Payment Amount:
	* Do NOT enter a $ symbol in the amount field. Instead, type in just the amount.

I confirm and verify that the patient listed on the form is the one filling out the form and I have permission to use the credit card to make payment.

I verify that the credit card being used is either my personal card or if another party or family member is making payment, I have their permission to use the credit card to make payment.

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