Birmingham Dental

Secure Payment Form

Patient information off statement
Order Date
Patient Name
Patient Account Number
Payment Amount
Name as seen on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date

3 digit number on VISA®, MasterCard® and Discover® branded credit and debit cards located on the signature line. On American Express® branded credit or debit card it is a 4 digit numeric code on the front of the card.

Email Addresss
Phone Number