Vascular Surgical Associates PC Business Office
Secure Payment Form * denotes required fields

Payment Summary:
Payment Date: 04/15/24
Payment Amount*:
Customer IP: 
Is payment for your balance or upcoming surgery?*
Credit Card Information:
Card Type:

Account Number with Our Office*:
Patient Name*:
Patient Date of Birth*:
Name on Card (if different from patient):
Card Billing Address:
Card Billing Zipcode:
Debit/Credit Card Number*:
Card Expiration Date*: MMYY
Card ID (CVV2/CID) Number*:
[What is the Card ID?]
Guarantor Information (must match debit/credit card Bill To information):
First Name*:
Last Name*:
Address Line 2:
Phone Number:
Email Address: