Direct/Self Pay Payment

Direct / Self Pay Payment Form

Round-up your payment to the nearest whole dollar amount.
There is a $10 credit card surcharge to cover processing fees for this payment form (automatically added to the total).

Member Name(Required)

First Last

Phone(Required)

Email(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Service For Which Payment Should Be Applied(Required)

Payment Amount(Required)

Please remember to round up to the next full dollar amount. Processing Fees are added separately on this form - do NOT add them here.

Processing Fee(Required)

Price:

Total

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Maestro

Card Number Expiration Date Security Code Cardholder Name