Gregory A Williams DMD PC

Secure Payment Form


Purchase Summary:
Date:	06/23/18
*Please pay balance in full, any partial payments will need to be arranged in office.
Payment Amount:
Patient Name:
Email Address: (receipt)

Credit Card Information:
Card Type:
Name as on Card:
Card Billing Address:
Card Billing Zipcode:
Card Number:
Card Expiration Date:	MMYY
Card ID (CVV2/CID) Number: [What is the Card ID?]




Gregory A Williams DMD PC 11820 SW King James Pl #40, Tigard, OR 97224 www.dentistintigard.com