Online Payment

Please complete the following Credit Card Authorization form. All fields must be completed accurately for your payment to be processed. Leaving any required field blank will invalidate your submission. Thank you.

Leaving areas with “Select One” as your answer will invalidate your submission

Credit Card Authorization Form

Patients Name (required)

Your Name (required)

Email Address (required)

Invoice #

Amount $ (required)

Credit Card (required)

Credit Card #(required)

Name on Card(required)

Exp Date(required)

CID #(required)

Credit Card Billing Information

Address(required)

City(required)

State (required)

Zip(required)

Phone #(required)

Terms Below (required)
Yes, I agree

I understand that the amount charged to my credit card will be reflected on my credit card statement within seven days of authorization. The amount charged is based on services requested or delivered by the ADD/ADHD Diagnostic & Treatment Center, PA