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

 
Payment Summary:
Payment Date: 10/22/18
Payment Amount*:
Customer IP: 54.196.26.1 
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*:
Address Line 2:
City*:
State*:
Zip*:
Phone Number:
Email Address: