Payment Form

*Indicates required fields.

*Guarantor First Name: The Guarantor First Name field is required.

*Guarantor Last Name: The Guarantor Last Name field is required.

*Patient First Name: The First Name field is required.

*Patient Last Name: The Last Name field is required.

*1st Choice Pediatrics Account Number: The Account Number field is required.

*Address: The Address field is required.

Address line 2:

*City: The City field is required.

*State: The State field is required.

*Zip: The Zip field is required. ex. 99999

*Phone: The Phone field is required. ex. 903-555-1212

*Email Address: The Email Address field is required.

*First Name as it appears on credit card: The Billing First Name field is required.

*Last Name as it appears on credit card: The Billing Last Name field is required.

*Address: The Address field is required.

Address line 2:

*City: The City field is required.

*State: The State field is required.

*Zip: The Zip field is required. ex. 99999

*Card Type:

Visa

Mastercard

*Card Number: The Card Number field is required.

*Card Expiration Month:(mm) The Card Expiration Month field is required.

*Card Expiration Year:(yy) The Card Expiration Year field is required.

*Security Code: The Security Code field is required.

*Payment Amount: The Amount field is required and must be a numeric value.

Special instructions or additional information: