On-Line Payment

  • If you would like to pay a portion or all of your open balance, please use the form below.
  • We use a Secure Payment process, powered by Pay-Pal. Please enter your Name and Birth Date so we can credit the correct account with your payment.
  • After you click on the “Pay Now” button, you will be taken to a secure PayPal driven web site, where your payment will be processed.
  • After the payment process, you will have a chance to enter any “comments or instructions” regarding your payment.

 

Patient Last name, First name
Patient Date of Birth

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