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Watts Eye Payment Form
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2017-07-06T01:14:25+00:00
Watts Eye Associates - Payment Form
Your payment information will be securely submitted to the office - you will receive a receipt within one business day.
Patient Name
*
First
Last
Patient Date of Birth
*
MM slash DD slash YYYY
Billing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name on Credit Card (if different from Patient Name)
First
Last
Email
*
For receipt
Credit Card Type
*
Visa
Mastercard
Discover
American Express
Credit Card Number
*
Credit Card Number
*
Security Code
*
Expiration Date
*
Amount of Payment
*
Signature
*
I authorize Watts Eye Associates to charge the amount specified to my card.
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