PRIMARY HEALTH CARE INC
Secure Payment Form

 
Payment Summary:
Payment Date: 04/19/14
Payment Amount:
Account Number: On your statement immediately after your name
Patient Name:
Patient Date of Birth: MM/DD/YY
           
Credit Card Information:
Card Type:

Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
 
[What is the Card ID?]
Email Address:
Email receipt: