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Patient Name  


    [authorize* authorize-957 "Continue to Billing"]

    By entering your credit card information, (i) you acknowledge that you are an authorized user of the credit card and that the associated information entered (account holder name, account number, billing address, etc.) is accurate, and (ii) you authorize Avantic Lab to charge the amount you have requested to your credit card.

    Payment is not complete until you click the “submit” button. Avantic Lab will send an electronic acknowledgement to you that the transaction has occurred. If you have opted out of receiving electronic communications, you will receive a formal receipt from Avantic Lab in the mail. It may take up to three(3)business days to process a payment. Avantic Lab shall not be liable for any payments that are not properly processed due to you quoting incorrect personal details or due to your credit/debit card supplier refusing or declining payment. For each transaction, in addition to the charge you have authorized, your credit card issuer and network may assess their customary transaction or handling charge, if any. If a charge is declined or reversed by the credit card issuer or network, you agree to pay a service charge and to reimburse Avantic Lab or all reasonable costs of collection. User’s credit card issuer may also assess its customary charge for such transactions.

    Created By Cloud9 Technologies
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