subject_line
Pay Online
Which Office Do You Primarily Use?
(Please select)
*
Manhattan Location
Roslyn/Long Island Location
Please Select Type of Payment
(Please select)
*
Pay Your Balance
Standard Service Plan
Extended Service Plan
Post-Laser Professional Care Plan
Patient Information
Patient First Name
*
Patient Last Name
*
Birthdate (mm/dd/yy)
*
Billing Address
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
Credit Card Information
Amount to Pay
*
Name on Card
*
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
CVV Code
*
Expiration Date (mm/yy)
*