Pay Online

 

Please enter the patient's account number below. This can be found in the upper right hand corner of the patient's billing statement. If you do not have the account number, please enter the patient's full name and address.

 

Include your email address when entering your billing information, if you would like a copy of your receipt to be emailed to you.

 

There will be a short delay as you are redirected to our secure payment form.

 

*Required field.

FDGG Connect Sample for ASP


Patient Name:
Patient Number:
First Line Patient Address:
Second Line Patient Address:
City:
State:
Zip Code:
* Enter Payment Amount:

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