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Secure Payment Form

Purchase Summary:
Date: 10/16/19

*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