Please complete the following form to complete your payment.  Tx:Team cannot accept prepayments or deposits, only payments towards services that have been rendered and have appeared on an existing Tx:Team statement.  Please complete all required fields (*).

Payment Form

Location of treatment*
Patient First Name*
Patient Last Name*
Amount shown in pay this amount*
Amount I am paying today*
Statement Number*
Statement Date*
Address*
Account Number*
City*
State*
Zip Code*
Email Address*
Country*
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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