Allergy & Asthma Specialists Physician Profiles Patient Services Contact Information & Directions Office Policies News, Important Announcements, Updates and New Patient REgistration Forms
 
This is a Secure Form
 
This form is for credit card transactions only.
  
Patient's Name
Patient Account Number
Payment Amount
Credit Card Number
Expiration Date
Security Code
Card Type
Cardholder Name
Cardholder Billing Address
Email Address

YOU WILL RECEIVE AN E-MAIL CONFIRMING YOUR ONLINE PAYMENT.
PLEASE ALLOW 48 TO 72 HOURS TO PROCESS YOUR REQUEST.
 

   
 
3955 Okemos Road Suite A1   |   Okemos, Michigan 48864         (PHONE) 517.349.0027   (FAX) 517.349.5882