If you have any questions, please call our Finance Department

Monday - Friday 8am to 4:00pm at 419-281-7107. 

 

Thank you.

Payment Information

Donation Amount*
$

* PLEASE NOTE*

 

ABOVE:  Enter amount to be paid in box that says "Donation Amount

This amount will be applied to your patient invoice 

 

BELOW:  Enter invoice number in the box that says"Patient Account #"

 

 

Patient Account #*

Patient Information

Country*
Email*
Confirm Email*
Phone*

Payment Information

Amount*
$
Payment Type
We only accept credit/debit card payments. After you complete this form, select Submit to enter your card details into our secure transaction processor. Your submission will be processed when you finalize your secure payment information.
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