[vc_row css=”.vc_custom_1441320640688{margin-top: 20px !important;}”][vc_column width=”1/2″][vc_column_text css_animation=”left-to-right” css=”.vc_custom_1441320656051{padding-right: 35px !important;padding-left: 100px !important;}”]

Online Payments

Please fill out the form below (including patient name) and input the amount you’d like to pay on your account. Upon clicking the button below, you’ll be redirected to a secure payment gateway where your credit card information will be collected.
Cardholder first name:

Cardholder last name:

Patient name (if different):

Payment amount:[/vc_column_text][/vc_column][vc_column width=”1/2″][vc_single_image image=”178″ img_size=”full” alignment=”center” css_animation=”right-to-left”][/vc_column][/vc_row]