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