Credit Card Bill Payment

Please complete and submit the secure form below and follow the instructions to complete the payment process. If you have questions or concerns, please contact our office at 770-951-8427.

Note: This payment form is NOT for patients to pay medical bills.

Credit Cards Accepted

Client Account Information

Client Name:
Account or Invoice #:
Comments:
Telephone Number:
Email Address:

Credit Card Information

First Name:
Last Name:
Street Address:
City:
State:
Zip Code:


Credit Card Type:
Credit Card Number:
Expiration Date:	/
Credit Card CCV:	(3 or 4 digit security code)
Payment Amount: