Patient Payment Form Patient Name* Patient Account Number Patient Date of Birth Contact Number* Email Address* Used for sending confirmationOther Contact NumbersDay: Evenings: Cell:Current Address*Is this a new address?NoYesCredit Card Type* Visa MasterCard Discover American Exp Name 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? No Yes Has Your Insurance Carrier Changed?* No Yes Name of New Insurance Carrier* Group Number* Policy Number* Is this your primary carrier? Yes No Do you have more than one healthcare insurance carrier?* No Yes Please list your secondary insurance carrier* Group Number* Policy Number* Do you have a third insurance carrier?* No Yes Please list your third insurance carrier* Group Number* Policy Number*
