Payment Page

2221 Ford Parkway #210 • Saint Paul, MN 55116 • 651-690-2020

Invoice Date

Customer #

Patient Name (If different than name on card)

Total Amount Due:

PLEASE NOTE: For security reasons, payments of less than $10.00 cannot be made on this payment page. Please call the clinic and we can process these smaller payments for you. Thank you.

Payment Info

Payment details

Card Number

Expiration Date

Security Code (CVV)

Billing Info

First Name

Last Name

Address 1

Address 2

City

State

Zip/Postal Code

Country

Email Address

Phone #

IMPORTANT: Please note this is a secure payment page only. A receipt will come from an email address that is a "donotreply" address. Please do not send an email to this "donotreply" address since it will not be seen. Please phone the clinic with any questions or other communication. Thank you.

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Payment Info

Payment details

Billing Info

Payment Page