Redmond Kids Dentistry Payment Form

Please fill out the form below. Required fields are marked with asterisks (*).

 

Contact Information

Patient's First Name: *

Patient's Last Name: *

Home Phone:

Other Phone:

Email Address: *

 

Payment and Credit Card Information

Please enter your payment amount and credit card information below.

Name on Card:

Card Type

Visa Mastercard  

Payment Amount ($):

Credit Card Number:

Expiration Month:

Expiration Year:

CVV Number (on back of card):

 

Billing Address Information

Address: *

City: *

State: *

ZIP: *

 

Thank you for paying your bill online. You will receive a confirmation email and a receipt for your payment.

 
 
 

You must agree to the payment on the next page to complete your transaction. It may take a minute, thank you for your patience.












This is a secure form.

The Team  | Kids  | Tour Our Office  | About Our Office  | Newsletters  | FAQs  | Patient Forms  | Contact Us  | Meet Dr. Stephanie  | Meet Dr. Merchant  | Meet The Staff  | Services  | Children With Special Needs  | Post-Op Instructions  | Prevention FAQs  | Diet and Nutrition FAQs  | Emergency FAQs  | Fluoride FAQs  | General FAQs  | Links




Redmond Kids Dentistry | www.redmondkidsdentistry.com | (425) 558-4562
16650 NE 79th Street, Suite 100, Redmond, WA 98052



 

 

Copyright © 2011-2017 Redmond Kids Dentistry and WEO MEDIA. All rights reserved.  Sitemap | Links