AFC URGENT CARE - FLORHAM PARK
CREDIT CARD PAYMENT FORM
AFC Urgent Care Florham Park, NJ
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
Patient's Last Name
Patient's First Name
Patient's Acct# (From statement, if available)
Payer Email Address
Please Re-enter Email
CREDIT CARD INFO & AUTH (Encrypted for your security)
Credit Card Type
Name on Card
Credit Card Number
Expiration Date (MM/YY)
Sec Code (Amex-4 digits, Other 3-digits)
Amount Authorized (US$)
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.