Online Bill Payment

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Source

hidden field populated by querystring source

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vid

Method of Payment

Credit Card

Cash

Check

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Clinic

Populated by query string variable cid with clinic ID number

Patient Name(Required)

First Last

Patient Date of Birth(Required)

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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

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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)

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