Vascular Surgical Associates PC Business Office
Secure Payment Form
Payment Summary:
Payment Date:
04/22/18
Payment Amount:
Customer IP:
54.81.166.196
Balance on Account or Surgery PrePay:
Credit Card Information:
Card Type:
Visa
MasterCard
Discover
Account Number:
Patient Name:
Patient Date of Birth:
Name on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date:
MMYY
Card ID (CVV2/CID) Number:
[
What is the Card ID?
]
Patient Information:
First Name:
Last Name:
Address:
Address Line 2:
City:
State:
Zip:
Phone Number:
Email Address: