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Please enter the information requested below. The guarantor is the patient if the patient is age 18 or older. If the patient is under 18, the guarantor is the person that brought the patient in for the visit.
Amount To Pay:$
(Enter dollar and cents in the form of xx.xx)
Patient Full Name:
(As it appears on the patient statement)
Patient Account Number:
(As it appears on the patient statement)
Email Address:
Pay By: 
Credit/Debit card