(205) 879-7888
|
2815 Independence Drive
|
Birmingham, AL 35209
Home
About Us
Our Practice
Our Physicians
Our Staff
Patient Care
Services
Prescription Refills
New Patient Registration
Important Forms
Photo Gallery
News
Articles
Updates
Helpful Links
Contact Us
Pay Online
Payment
Patient Information
Patient Name *
Guarantor Name *
Account Number *
Amount
Cardholder's Name *
Cardholder's Email *
Card Type *
Select the card type
Discover
MasterCard
Visa
Expires *
[01] January
[02] February
[03] March
[04] April
[05] May
[06] June
[07] July
[08] August
[09] September
[10] October
[11] November
[12] December
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
Card Number *
Security Code *
Address
City
State
Select State/Prov
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Country
United States of America
Canada
Zip
Phone