Billing Information  
 
  
Patient ID
  
First Name
 
MI
 
Last Name
   Address
  
  
City
  
State
  
Zip Code
  
Phone
  
Work Phone
  
E-mail (required for an emailed receipt)
  
 
   Payment Information  
  

Payment Amount
 
  Please select a payment method
Checking Savings Credit/Debit Card
  Notes

 
 
* Attention *

Partial payment does not reflect a 'payment in full.'
You are responsible for the full amount of the balance due.

If you need to arrange a payment plan please contact us for more information. If you have any questions or would like to speak to a representative, please call (502) 587-4397.


This is a secure site. All of your information is secure and confidential.