Online Patient Payment Center
Welcome to the Online Payment Center.
For your convenience please fill out the below payment form. All information will be kept secure and confidential. For more information you may call our business office during working hours.
Name Of Patient
Name of Patient Treated.
Invoice Number (optional)
Invoice Number. (Should Be Located On Your Bill, This is Optional)
Name of Payor
Payor's Name on Credit Card or Checking Account.
Address Where Your Credit Card or Bank Account Statements Are Mailed.
City, State, Zip
Please Include Your City, State, and Five Digit Zip Code.
Home Telephone Number
Your E-Mail Address
Please Provide An E-mail Address.
Amount of Your Payment
Please Specify How Much You Are Paying. Please Use Dollars and Cents.
Credit Card Type
Select If You Are Paying By Credit Card.
Credit Card Number
Input The 16 Digit Number Just As It Appears On Card.
Credit Card Expiration Date
Comments Or Messages Related To Your Payment