Make a Payment

Complete this form to make a payment.

Name*
First Last
Email*
Phone*
Please select the service you are paying for:*
- Professional Services
- Facility Fees
- Anesthesia
Please select your physician from the drop down menu:*
Please select your payment type:*
- Surgery Deposit
- Outstanding Bill
- Remote Consult
Surgery Deposit*
Price: $500.00
Outstanding Bill Amount:*
Please enter the payment amount for the balance of your bill.
Outstanding Bill Amount:*
Please enter the payment amount for the balance of your bill.
Select Your Consultation Type from the drop down menu:*
Outstanding Bill Amount Due:*
Please enter the payment amount for the balance of your bill.
Total
$0.00
Non-Refundable Payment Acknowledgement:*
- I understand that this is a non-refundable deposit.
Payment Information:*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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