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Choose a Payment Method

Account Information

Account number

Patient Name

Payment Information

First name

Last name

Card number

Expiration date

Security code

Address 1

Address 2

City

State

Country

Zip

Zip plus 4

Email address

Phone number

Payment ($)

You are agreeing to pay $ plus a Fee of $ (%) for a Total of $.

Confirmation

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By checking the box to the left, you are indicating that you give University Pediatric Dentistry authorization to process the above payment of $.

By checking the box to the left, you are indicating that you give University Pediatric Dentistry your authorization to process the payments as outlined in the payment schedule above using the payment method listed above. To revoke your authorization you must contact University Pediatric Dentistry.

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