Order Info
Payment for supplements, labs, injectables, coinsurance (including copays and deductibles). Minimum $5.00, Max $2,000

Pay by Credit Card

Pay by Check

Account Information * Indicates a Required Field Invoice Number  * Payment Amount  * Card Number  * CVV2  * Expiration Date  * MM 01 02 03 04 05 06 07 08 09 10 11 12 / YYYY 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 Zip  * Routing Number * Account Number * Name on Account * Account Type * Checking Saving Description *

Billing Information Contact Name * Address  * Address 2 City  * State  * Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Colombia Manitoba New Brunswick Newfoundland Nova Scotia NW Territories Nunavut Ontario Prince Edward Quebec Saskatchewan Yukon Zip  * Cell Phone # Telephone # Email Purpose of Payment - Please include Patient Name if different than cardholder Send Email Receipt