Online Payment

Use this form to make payments for:

• Your upcoming surgery


• Scheduling deposit


• Your existing payment plan

Paypal Payment for specific amounts:

Payment Form

If you are human, leave this field blank.

Patient Name *

Email

Appointment Date

(mm/dd/yyyy)

Reason for Payment *

Payment for upcoming visit or procedure

Scheduling / reservation deposit

Payment for my existing payment plan

Online second opinion

Payment Amount in USD *

For the exact amount due, contact us via email or call us at (301) 654-7070

Submit

Important Notes

• You may make online payment for your upcoming surgery or visit. Please speak to our treatment coordinator about the exact fees.


• Your payment will be credited to your account. On the day of surgery, your payment will be posted towards services provided.


• Your payment is fully refundable if surgery is canceled for any reason. If you have an existing balance from prior visits, it will be deducted from your payment.

• The scheduling deposit is $500.00 for surgeries which will be credited toward services. This will confirm your reservation for the given appointment.


• There will be a $25 charge for any cancellations made on the day of appointment.


• There will be a $50 charge if you fail to keep your appointment with no prior notification.

• Please refer to your agreement for the exact amount of your monthly payment.

• The fee for obtaining online second opinions is $175.00


• Please click here for instructions on how to send records.