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Online Payment Form

 

 

Doctor's Billing Online Patient Payment Center

* Name of Clinic:

* Name of Patient:
* Your e-mail address:
* Amount of Payment:
* Name on Credit Card:
* Card Number
* Expiration Date:
Would like a receipt e-mailed?
 

Note: By using this service, payer acknowledges agreement with the privacy and security policy of Doctor's Billing, listed here.