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         Secure Payment Form

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Patient Information:
    First Name: *
    Last Name: *
           
Credit Card Information:
    Payment Amount: *
    Card Type:

    Name as on Card: *
    Card Billing Address: *
    Card Billing Zipcode: *
    Card Number: *
    Card Expiration Date: * MMYY
CVV2/CID Number: *
    [ What is the Card ID?]
    Phone Number:
    Email Address:
   
   Thank you for your payment!