ONLINE PAYMENTS

 

Cardholder Information
* Cardholder First Name
* Cardholder Last Name
* Cardholder Phone Number
* Cardholder Email
* Cardholder Billing Address
* Cardholder Billing Zip
Comments
Shipping Information
* Patient First Name
* Patient Last Name
* Patient DOB (MM-DD-YEAR)
Amount
  $
* Required Fields

 

*** Limit of one payment per day up to $500 if credit card not on file with us. ***

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We appreciate your business!