Make A Payment

 

Important Notice: As of August 18, 2010 we are no longer accepting any payments for PM Pediatrics of Rockland, as we are no longer affiliated with them. Please contact them directly at (845) 357-5437 for payment instructions. Thank you.

 


Billing Information
(fields with asterisk (*) are required)


* Patient First Name:
* Patient Last Name:
* PM Pediatrics Account Number:
* Address:
Address 2:
* City:
* State:
* Zip Code:
Phone Number:
* Email Address:
* PM Pediatrics Location:


Payment Information
(as it appears on the credit card)


* First Name:
* Last Name:
* Card Type:
* Card Number:
* Expiration Date: 
* Security Code:
* Payment Amount:   Example (100.00)




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