Patient Payments (Seattle)

Step 1 of 2

Patient Information - Seattle

Please complete the following information. We will only contact you if there are issues with your payment.

Patient Name(Required)

First Last

Email(Required)

Where the payment receipt will be sent.

Enter Email Confirm Email

Phone Number(Required)

The phone number we should call if there is an issue with the payment.

Invoice Number(Required)

Please input your Invoice Number which should start with "CF" for example, "CF1234". If you do not have your invoice number, input "IDK" for I don't know.

Payment Amount(Required)

This is the amount you are paying on your amount due

Billing Address(Required)

The most frequent reason cards fail is due to a mismatched zip code. The billing zip code is usually where the credit card statements are sent.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address(Required)

Same as billing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Total Payment

Credit Card(Required)

American Express

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name