Please use the form below to submit an online payment. Payments are made via PayPal and can be either Visa, Mastercard, American Express, or Bank Transfer. Please note that a 3% service charge is added to all online or credit card payments. Patient's Name* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact Phone*Email* Date of Service Date Format: MM slash DD slash YYYY Invoice Number*Payment Amount* Online Service Charge Price: $0.00 This fee is automatically added to all online invoice payments and is 3% of the payment.Total Payment $0.00 Δ