Payment Process | UNIVERSAL DIAGNOSTIC LABORATORY

Payment Form

Payment Form

Please fill out Account information and Credit Card info with the payment card.

Account Information

First Name

Last Name

Address

City

State

ZIP Code

Mobile No

Email Address

Payment Information

Date of Service

Statement Id

Amount

Notes

Credit Card Info ( )

Credit Card Number

Expiration

CVV

Acknowledgement to Pay:

I authorize the charges to my credit card entered above.