Secure Credit Card Payment Options

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If you wish to set up a recurring payment please contact billing at 610-626-8085 xx 1006, or at Billing@PsychChoices.com

Payment Form

Patient First Name*
Patient Last Name*
Email Address*
Practitioner/Other (Optional)
Payment Amount*
Payment is For (Optional)
Zip Code (Optional)
Cardholder`s name*
Billing address (Optional)
City (Optional)
State (Optional)
Country (Optional)
Additional Comments
Payment Method*
Credit Card Number*
Expiration Date (MM/YY)*
Security Code*
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