Online Bill Payment

Hidden

Source

hidden field populated by querystring source

Hidden

vid

Method of Payment

Credit Card

Cash

Check

Hidden

Clinic

Populated by query string variable cid with clinic ID number

Patient Name(Required)

First Last

Patient Date of Birth(Required)

Hidden

Patient Age

{Patient Date of Borth:21:age}

Name of adult responsible for minor patient(Required)

First Last

Patient or Parent Phone(Required)

Patient or Parent Email(Required)

Account number from Invoice (if available)

Amount to pay(Required)

Hidden payment currency

Price:

Total to pay

Check Number

Hidden

Secure Credit Card Payment(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Type Your Name as Electronic Signature(Required)

Hidden