Garrett Orthodontics, P.C.
Secure Payment Form
Order Summary
Payment Amount
Patient Name
Email Address for Receipt
Patient Number REQUIRED
Credit Card Information
Pay By Check
Name on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date
CVV2/CID
Pay By Check
Pay By Credit Card
Name as on Check
Bank Routing Number
Bank Account Number
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