Checkout : Metropolitan Pediatrics

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Billing details

Patient Information

Account Number *

Patient First Name *

Patient Last Name *

Parent Information

First name *

Last name *

Phone *

Email address *

Street address *

Apartment, suite, unit etc. (optional) (optional)

City *

State *

ZIP *

Payment Information

Payment Amount *

Terms & Conditions

I authorize Metropolitan Pediatrics, LLC, to charge my debit or credit card the Payment Amount indicated on the online bill pay form. I acknowledge that I am responsible for entering the correct Payment Amount and all other required information, and that I am initiating a charge to my card compliant with U.S. law. By submitting an online payment, I agree that I possess funds sufficient to cover the Payment Amount entered, and agree that Metropolitan Pediatrics, LLC, is not liable for any overdraft or insufficient funds penalties. I understand that it may take several business days for an online payment to be processed and applied to my account.

I agree with the terms & conditions. *

Total

Product	Subtotal
Online Payment × 1	$0.00
Subtotal	$0.00
Total	$0.00

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