Patient Payment Form Patient Name*Patient Account NumberPatient Date of BirthContact Number*Email Address*Used for sending confirmationOther Contact NumbersDay: Evenings: Cell:Current Address*Is this a new address?NoYesCredit Card Type*VisaMasterCardDiscoverAmerican ExpName as it appears on credit card*Credit Card Number*Credit Card Expiration Date*Security Code on Credit Card*American Express cards have a four-digit code printed on the front side of the card above the number. Discover, MasterCard, and Visa credit and debit cards have a three-digit card security code. The code is the final group of numbers printed on the back signature panel of the card.Total to be charged $*Mail Receipt?NoYesHas Your Insurance Carrier Changed?*NoYesName of New Insurance Carrier*Group Number*Policy Number*Is this your primary carrier?YesNoDo you have more than one healthcare insurance carrier?*NoYesPlease list your secondary insurance carrier*Group Number*Policy Number*Do you have a third insurance carrier?*NoYesPlease list your third insurance carrier*Group Number*Policy Number*