Back & Neck Clinic of New Prague

Secure Payment Form

    
Date
Amount

PLEASE ONLY PAY FOR 1 PATIENT ACCOUNT PER TRANSACTION.

Account Number
Patient Name
Phone Number
Name as on Card
Card Billing Address

ADDRESS, CITY, STATE

Card Billing Zip
Card Number

FULL CARD NUMBER NO SPACES

Card Expiration Date

TWO DIGIT MONTH AND YEAR

CVV2/CID