From the drop-down list, please select one of two options: “Deposit for future services” or “Payment toward account balance.” This is a required field.
Select an option... Deposit for future services Payment toward account balance
From the drop-down list, please select where you receive your service.
Select an option... Savannah Statesboro
Please provide the name of the patient whose account will be credited with this payment. This may be different than the name of the person making the payment. This is a required field.
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