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Payment via Credit Card to Chiro2me
Thank you for submitting your credit card information. We impose a surcharge of 3.9% (plus an additional $.50) on the transaction amount on all credit card payments for services, not greater than our cost of acceptance. We will also use the card on file for any copays, deductibles and/or balances due.
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Email
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Your email
If you prefer to avoid the surcharge fee for the credit card, here are other options to pay:
Card Holder's Full Name
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Your answer
Patient's Name (paying for)
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Your answer
Amount to be paid on credit card
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Your answer
Credit Card Number
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Your answer
Credit Card Expiration Date
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Your answer
CVV
*
Your answer
Credit Card Zip Code
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Your answer
Please type in your full name for credit card authorization:
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Your answer
Date
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