New Clients: Print and fill out these forms and email them to me at firstname.lastname@example.org
Please fill out the Credit/Debit card form:
If you would like to pay your fee or copay by credit card
If you have an unpaid deductible for this year
Please enter all information except credit card number, expiration date and CCV number. You can give these to me over the phone.
|Credit/Debit Card Form|
Note: To download Adobe Acrobat Reader for free, click here.