Best Card Online Payments

To pay online, please complete the form below.

Recurring Information

In addition to $36.00 today, you will be charged $36.00 every 30 days starting on the next applicable future date.

Billing Information

Cardholder first name *

Cardholder last name *

Patient Name

Billing Address *

Billing City *

Billing State *

Billing Zip *

Phone number

Today's payment amount: $36.00

Cancellation Policy +

The business maintains the right to, if necessary, initiate adjustments for any transactions credited/debited in error. Should cardholder wish to amend or cancel payment plan detailed below, they must submit written notice at least 10 days before payment date and understand that they are still liable for balance owed for services/products rendered.

I guarantee that I am the legal cardholder for this credit card, that I am legally authorized to enter into this billing agreement.