Please complete the following form to submit your payment.   Please complete all required fields which are marked with an asterisk (*).

Payment Form

Location of treatment*
Patient First Name*
Patient Last Name*
Amount I am paying today*
Statement Number
Statement Date
Account Number
Address*
City*
State*
Zip Code*
Country*
Email Address*
Payment Method*
Credit Card Number*
Expiration Date (MM/YY)*
Security Code*
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Questions regarding your statement?  Please contact Tx:Team Accounting at 317-756-9712.

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