AFC URGENT CARE - FLORHAM PARK | CREDIT CARD PAYMENT FORM

If you are paying balances owed on multiple statements, please submit separate payments, one submission of this form for each statement.

Please fill in all the required (*) fields below.

PATIENT / PAYER INFO

CREDIT CARD INFO & AUTH (Encrypted for your security)

Visa
Please allow up to 3 business days for the payment to post to the patient account identified above. The actual charge to your credit card account will serve as your receipt.
By entering my name below as my signature, and clicking "SUBMIT", I hereby authorize AFC Urgent Care to charge my card for the amount shown.
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