Make a Payment

Step 1 of 2 - Contact Info

Contact Information
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Parent/Guardian Phone*
Patient Information
Patient's Name*
First Last
Patient's Date-of-Birth*

Payment Information
Select Location*
Payment Amount*
Enter the amount you would like to pay here.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State ZIP Code
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Convenient Locations
in Chandler and Gilbert