Secure Payment Page

Patient Information

Name *

Surname *

Phone Number *

Email *

If someone other than the patient is making the payment, please check this box.

Payment Information

Payment Type *

Amount * No utilice . ni ,

Currency *

Details / Notes (Optional) * For payments made on behalf of multiple people, please specify the full names of all individuals undergoing the procedure in the description field.

Important Information

You can only make payments with Visa and Mastercard.
For your security, all payments are processed with 3D Secure. Your card must support 3D Secure transactions.
Your card must be enabled for online payments.
Your card must be open to transactions in the selected currency.

Important Information

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