Make a

PAYMENT

For your convenience, please use our secure online payment portal. No login is required.

Please complete all fields and click submit. Only click “Submit” once, or else a duplicate payment may be created.

You will see a confirmation screen upon the successful completion of your transaction.

If you have any questions, or would rather make your payment by phone, please call our billing department at (833) 233-2455.

Payment Information

Amount: $

USD

Patient Name / Date of Service:

First Name:

Last Name:

Address:

City:

Country:

State/Province:

ZIP/Postal Code:

Phone:

E-mail:

I have:

Card Number:

Name on Card:

Expiration Date:

CVV: