Please fill out the form below if you are a patient and would like to make a payment with a credit or debit card.






Patient Name (required)

Payment Amount (required)

Account Number (if available)

Card Holder Name (required)

Type of Card? (required)
VisaMastercardAmerican ExpressDiscover

Card Number (required)

Expiration Date (required)

3 Digit Code from back of card (required)

Billing Zip Code (required)

Please fill out the form below if you are a patient and would like to make a payment with an Echeck.






Payment Amount (required)

Date to Withdraw Funds (required)

Account Type? (required)
CheckingSavings

Routing Number (required)

Account Number (required)

First Name on Account (required)

Last Name on Account (required)

Phone Number (required)

I authorize Liberty Medical Solutions, LLC to initiate either an electronic debit or to create and process a demand draft against my bank account on or after the date indicated above for the amount indicated above. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law. (required)