Online Payment – Dental Clinic Lincoln NE

Chart (Account) Number*
Amount*
Name*
First Last
Email*
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Total
$0.00
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PayPal Payment Instructions

After filling out the form shown you will be taken to the PayPal payment portal screen. At the bottom of this screen is a button you can select to pay with your debit or credit card. You do not need to have a PayPal account for your payment.