Make a Payment Email Us Call us Complete this form to Make Your Payment Name:(Required) First Last Email Address:(Required) Please select the service you are paying for:(Required)Office / Video AppointmentSurgery DepositNon-Refundable Payment Acknowledgement:(Required) I understand that this is a non-refundable deposit. Credit Card Authorization:(Required) I understand that this online payment represents my authorization to charge the credit card provided for the services rendered and attest that I am authorized to use the credit card and agree to the charges associated with such services. I hereby confirm that the information provided is true and correct and agree that should any dispute arise, I will first contact the merchant before taking any action.
