Valley Health - Reproductive Health Clinic
On-Line Credit Card Payment
 
You can now submit your payment on-line towards your Valley Health statement. Please fill out all fields. Incomplete forms will not be processed for payment.
Secure Credit Card Payment
Patient Name (First & Last)
Patient Account Number (if available)
Patient Date of Birth
Payment Amount
Contribution Amount (optional) **Please remember that Valley Health is able to keep costs to a minimum through contributions from our patients.
Credit Card Type
Visa
MasterCard
Discover
Credit Card Number (16-digit xxxx-xxxx-xxxx-xxxx format)
Credit Card Expiration Date (mm/yy)
Security Code (XXX found on back of card)
Card Holder Billing Information
Name On Card
Street Address
Street Address
City, State
Zip Code
Phone Number
I authorize Valley Health to charge the above listed card for the amount specified.

Todays Date
 
 
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