Progressive Medical Associates PLLC

Apply co-payment to the following patient account:

First Name * Last Name * Amount of Payment *

CREDIT CARD INFORMATION

Cardholder's First Name * Cardholder's Last Name * Credit Cards Accepted * Card Number (No Spaces) * Expiration Date (MM/YY) * CVV Code * Billing Address with City and State * Billing Zip Code *

By submitting this form, I authorize Progressive Medical Associates to charge my credit card for the amount indicated above.

Signature *