DOUGLAS A WALDMAN MD PA
Secure Payment Form

 
Order Summary:
Order Date: 02/17/18
Payment Amount:
Account Number:  
Customer IP: 54.167.5.113 
Patient Name:  
           
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: