Make a Payment for Appointments & Labs

Use the form below to pay for medical appointments, counseling appointments, dental appointments and labs.

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Layout

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Birthdate (mm/dd/yyyy)

Email

Payment For (select one)

Amount (Your co-pay or lab pre-pay)

Minimum Price: $10.00

Authorize.Net

Card Number

Expiration

/

Security Code