html> Florida Lions Eye Bank

Florida Lions Eye Bank
Secure Payment Form

Payment Summary: 2 Month Supply Monthly Payment
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Payment Date: 04/15/24
Payment Amount: $145.00
Recurring Payment Information:
Recurring Amount $145
Start Date
Number of Payments 2
Credit Card Information:
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Card Type:

Name as on Card: *
Card Billing Address: *
Card Billing Zipcode: *
Card Number: *
Card Expiration Date: MMYY*
Card ID (CVV2/CID) Number:
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Patient Information:
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Patient First Name: *
Patient Last Name: *
Patient Phone Number: *
Patient Email Address: *