Patient Name(Required)
Relationship to the patient(Required)
MM slash DD slash YYYY
Address(Required)
Credit Card(Required)
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
Effective June 1st, 2024, we will be imposing a 2% surcharge on the transaction amount for all credit card payments.

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Effective June 1st, 2024, we will be imposing a 2% surcharge on the transaction amount for all credit card payments.