Vascular Surgical Associates PC Business Office
Secure Payment Form * denotes required fields
Payment Summary:
Payment Date:
12/02/24
Payment Amount*:
Customer IP:
18.97.9.170
Is payment for your balance or upcoming surgery?*
Credit Card Information:
Card Type:
Visa
MasterCard
Discover
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: