Rochester Gastroenterology Associates
 
 

 

 

 


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Installment Payments
(Secure Form)
Please provide your Credit Card information for verification.
You will proceed to calculate your monthly amounts.

Billing information (All fields are required)
First Name: (on Card)
Last Name: (on Card)
Address:
City:
State:
Zip:
Phone Number: xxx-xxx-xxxx
Email Address:
 
 
This will become a RECURRING MONTHLY PAYMENT METHOD.
Please proceed the next page to select monthly charges and patient information.

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Card Code : (3 digits on the back of your card)


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