Make A Payment Patient Name* First Last Patient Phone*Patient Email* Patient Account #Type of Payment:*Payment on AccountPrepayment on Surgery or TreatmentMethod of Payment*Credit CardCredit CardCardholder Name* First Last Cardholder Address - Must Match Billing Address* Street Address ZIP Code Cardholder Phone #*Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Payment Amount* Terms and ConditionsAll payments to Allure Medical using the online credit card or e-check facilities are subject to the following terms and conditions. It is your responsibility to: Ensure there are sufficient funds available in your checking account or credit card limits. If there are insufficient funds in your account, your financial institution may charge you a fee and/or interest. You are solely responsible for paying any fee and/or interest charged by your financial institution or Allure Medical Spa. If the transaction is refused by your financial institution for any reason, including, but not limited to, insufficient funds, closed account, or unauthorized account, or declined credit card, Allure Medical will not be able to process your payment. Your account may be subject to additional charges if your payment is rejected, reversed or refused by your financial institution and Allure Medical Spa incurs charges. Check your account statement to verify that the amounts debited or credited to your account are correct. Advise Allure Medical if the payment account or credit card is closed or not available three (3) days before the payment date. When you complete the online payment form, you are authorizing Allure Medical and Authorize.net to credit or debit your account for the amount determined by you in this transaction. By using Allure Medical’s online credit card facilities you agree to all applicable Allure Medical policies relating to your Internet resources. Funds will be deducted from your credit card or e-check account in US dollars. Due to the way transactions are processed by our payment processor, there may be delays of 1-3 days in updating your payment in Allure Medical records. Credit card payments will be processed directly by Authorize.Net using Secure Socket Layer (SSL) technology. Credit card numbers are protected with a high level of encryption when transmitted over the internet. Allure Medical does not have access to your credit card details. If successful, your credit card provider will confirm that the payment was completed. If unsuccessful, your credit card provider will advise you of same. Allure Medical will not be informed why a payment has failed; therefore please contact your financial institution or credit card provider for details. Allure Medical Spa’s Terms and Conditions for online credit card or e-check payments are subject to change at any time. Each transaction shall be subject to the specific Terms and Conditions that were in place at the time of the transaction.Terms and Conditions* Check to Agree to Terms and Conditions NameThis field is for validation purposes and should be left unchanged.