Pay Online | Raleigh Capitol Ear Nose & Throat

Pay Online

Secure On-Line Payment

Personal and Credit Card information is safe with our secure server and PGP software, a superior encryption algorithm (1024 bit) for e-mail.

For payment towards your balance, please enter the amount in the box below.

Please print a copy of your transaction receipt once you have completed your online payment.

Patient Name(Required)

Account Number(Required)

(Can be found at the top of your billing statement)

Amount(Required)

($10.00 minimum. Please enter using decimal. ex: 150.00)

Billing Info

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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