Make A Payment 2017-11-02T23:51:37+00:00

Make A Payment

1
Patient Information
ALM Confirmation #
If you know your Confirmation #, Please enter it here.
Patient Name:
2
Credit Card Information
Address Details (Must be the same as your Credit Card Account)
First Name:
Last Name:
Address:
City:
State:
Country:
Post/Zip Code:
3
Contact Information
Phone Number:
Email Address:
4
Payment Information
Credit Card Number:
Expiration Date:
Security Code:
5
Payment Amount
Amount:
No Commas Please
Total Amount:

Total Amount Includes 3% Credit Card Processing Fee.