TRIANGLE ARTHRITIS & RHEUMATOLOGY ASSOCIATES
Secure Payment Form
Payment Information
Please complete ALL FIELDS below to insure proper credit to Patient account
Payment Amount
*Patient's Date of Birth(required)
*Account Number (required)
Credit Card Information
We Accept Visa, MasterCard, Discover, American Express & Debit Cards
Card Number
Card Expiration Date
CVV/CID
Name as on Card
Card Billing Address
Card Billing Zip
Cardholder Information
Please enter email to receive receipt upon approval
Phone Number
Email Address*(required for receipt)
Practice Information
Submit
