Make a Payment

There is a 3.5% convenience fee for using a credit card. You may elect to forward a check or money order with your invoice to avoid this fee.

Name*
First Last
Email*
Patient ID Number*
Billing Address
Street Address Address Line 2 City State ZIP Code
Payment Amount*
Transaction Fee
Price: $0.00
Total
$0.00
Credit Card
Card Details
Cardholder Name
Comments
This field is for validation purposes and should be left unchanged.