Payment Verification

This page allows payment for services that would have been received from facilities managed by Physicians Alliance Limited.

To provide payment, please complete and submit the form below. On successful submission of form, you will receive a confirmation of successful processing on the screen and via email.

PATIENT / ACCOUNT INFORMATION

Patient Full Name:
Email Address:
Patient Address:
Telephone:
Patient Account/Billing Number:
Patient Details:

CREDIT CARD INFORMATION

Card Type:
Cardholder Name:
Exp Month and Year:
CVV:
Amount to Pay:

I confirm the above information are correct.