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Surgery Prepayment

Make prepayment on your surgery balance

$0.00

Patient Name

DOB (mm/dd/yyyy)

Order Policy

I certify I have an order for this surgery. If not, please schedule an appointment with our office.

Refund Policy

I will not be refunded if services are rendered. However, I acknowledge I will be refunded if my provider does not agree with the plan of care and services are not rendered.

Payment Amount

Please Enter the Amount You Are Paying = $1.00

Qty:

Business Day Delay

If payment made after hours, on the weekend or holiday, your payment may not be posted to your account until the next business day. Please show your emailed receipt at your upcoming appointment.

Qty

Description

Surgery Prepayment

My Account

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Surgery Prepayment

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My Account

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