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Procedure Prepayment

Make prepayment on your procedure.

$0.00

Patient Name

DOB (mm/dd/yyyy)

Order Policy

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

Refund

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.

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.

Payment Amount

Please Enter the Amount You Are Paying = $1.00

Qty:

Qty

Description

Procedure Prepayment

My Account

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Procedure Prepayment

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