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** Fields in Bold are Required **Patient Information
Patient Account Number
Patient First & Last Name


Payment Information
  Visa MasterCard Discover
Card Number Enter the number without spaces or dashes
Expiration Date
Card Code What’s this?
Payment Amount


Billing Information
First Name Last Name
Address
City
State Zip Code
Email Address To have your receipt emailed to you
Phone


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Questions about your bill or need payment arrangements? Call (719) 355-3428

 

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