Date
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Month
-
Day
Year
Date
Patient Last Name
*
Patient First Name
*
What is this payment for?
*
Nebulizer $50.00
Statement Balance
Co-Pay
Other
Payment Information
*
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( X )
USD
Payment Amount
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Paying with CareCredit is now an option
Select Pay Now below to pay on the CareCredit website.
Email address for payment receipt
example@example.com
Card Holder Signature
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