Authorize.net Payment Form

CREDIT CARD INFORMATION

Payment Amount (EXAMPLE: 10.00)*
Credit Card Number*
Expiration Month*
Expiration Year*
CVV Code*

CUSTOMER BILLING INFORMATION

MED7® Account Number (6 digits)*
First Name*
Last Name*
Address*
Address (cont.)
City*
State/Province*
Zip/Postal*
Phone (please enter number without spaces and beginning with area code)*
Email*

Use the following form to enter your patient information found on your MED7® bill. Add your payment information to submit your payment to MED7®.

 

IMPORTANT: You may locate your six digit MED7® Account number in the upper right hand corner on the billing statement. You may also see the number in parentheses, next to the Patient’s name on the billing statement.

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