MAKE A PAYMENT Make a one time payment with your credit or debit card Payment Details*This information is requiredPatient Name* First Last Date of Birth* Chart #* Statement # Payment Amount* Pay Additional Patient StatementsWould You Like To Add Additional Patients For This Payment?*Please Choose One1 Additional Patient2 Additional Patients3 Additional PatientsNo, Thank YouAdditional Patient #1 Name* First Last Additional Patient #1 - Date of Birth* Additional Patient #2 Name* First Last Additional Patient #2 - Date of Birth* Additional Patient #3 Name* First Last Additional Patient #3 - Date of Birth* Billing Details*This information is requiredCardholder Name* First Last Email* Phone*Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secure Credit Card Card Holder* Card Number* Card Expiration* Card CVV* Total $0.00 CAPTCHA