Payment Information Form

Please enter your billing information:
Account Information
E-Mail:*						Valid e-mail is required
Patient Name:*
Responsible Party Name:**
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
Phone:*
Credit/Debit Card Information
Card Number:*						No dashes or spaces please
Expiration Month:*
Expiration Year:*
Card Brand:*
Security/CVV Code*
I authorize Shannon Thomas, DMD to keep this information on file for billing purposes.*
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