Patient Information

Payment Information

 I Accept the Service Fee and its Terms and Conditions

THANK YOU FOR YOUR PAYMENT - If you have any questions or would like to talk to someone in customer support, please call 810-735-7815 during standard business hours: Monday through Thursday 8:30 am – 5:30 pm Eastern Standard Time.

TERMS AND CONDITIONS - By submitting payment information through this Service you agree to the terms and conditions of this Agreement. You further agree that this User Agreement forms a legally binding contract between you and  and that this Agreement constitutes “a writing signed by You” under any applicable law or regulation. Any rights not expressly granted herein are reserved by  . By clicking on the "Make Payment" button you are accepting these terms and conditions of this payment using this service. Please remember to print this form for your records.

PRIVACY POLICY - Personal Information: We do not sell, trade, rent or otherwise share for marketing purposes your Personal Information with third parties. In general, the Personal Information you provide to us is used to help us communicate with you or provide reasonable safeguards to verify identity. Non-Personal Information: In general, we use Non-Personal Information to help us improve the Service and customize the user experience. We also aggregate Non-Personal Information in order to track trends and analyze use patterns on the Site