Center For Discovery Payments

Account / Customer ID*

Patient Name*

First Last

Facility Location*

Notes

Name*

First Last

Email*

Phone*

Billing Information

Address*

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

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Payment Amount*

Enter the amount of payment to be made.