Texas Health Center for Diagnostics and Surgery
Secure Payment Form

Order Summary:
Date: 03/20/18
Account Number:
Patient First Name:
Patient Last Name:
Customer email:
Customer phone:
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?]

If you experience technical difficulties with this site, please contact Customer Service at 682-236-1600 or 800-715-7210.