Santa Ynez Valley Dental
Secure Payment Form
Please note:
A surcharge of 3% will be added to your payment for credit card transactions.
Payment Summary
Payment Date
Payment Amount
Surcharge (3%)
Total Amount
Date of Service
Patient Name
Credit Card Information
Name as on Card
Card Number
Card Expiration Date
CVV2/CID
Card Billing Address
Card Billing Zip
Email Address
Having Trouble?
You can also make a payment by calling us at (805) 688-2269; Monday - Friday 8am - 5pm
Submit
