Online Payment Page!

credit card processing


Yes, you can make a payment to an account "online" using you credit card and our payment form below.  Online credit card payments will be posted to your account within one business day.  You may also call us and we can process your credit card over the phone.

Your privacy is very important to us!  Therefore, to protect the confidentiality of the users of our site, all of the data that you type into one of our  "online" forms is encrypted before it leaves your computer and is not decrypted until it reaches our office.

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Patient's Name:
  Patient's Account Number (Optional):
  Name (As it appears on card):
  Card Type:
  Card Number:


Expiration Date: 
Security Code*:    
* For Visa, MasterCard & Discover - Last three digits on back of card.  For American Express - four digits on front of card above card number.
Card Holder Street Address:
Card Holder Zip: 
Amount you wish to charge$: $
Would you like a receipt mailed to the above address?

Yes No

Additional questions/concerns that you have:

In an effort to be GREEN, please use the "Submit" button to send your payment directly to us.

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Thank you for your payment!