Uptown Pediatrics
Pay Your Bill Online

Complete the form below to send your billing information to Uptown Pediatrics. Your credit card will be processed at our office. Please complete all fields in the form below.

Transactions will be processed within 24-48 hours and you will recieve an email confirming that your transaction has been completed.


Patient First Name:
Patient Last Name:
Account Number:
Address:
City:
State
Zip/Postal code:
E-mail Address:

Please enter a valid e-mail address.
Phone number:

Please supply your phone number.
Payment Amount Payment Method: Card Number: Expiration Date:
 
Name On Card: Billing Address City State Zipcode
Comments:

Can Uptown Pediatrics leave your credit card information on file?    Yes   No

   
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