Payment Plan Form

Simply complete the credit card information section below. All requested information is required. Upon approval, we will automatically bill your credit/debit card for the written amounts below.

$650.00 payment due today

1 payment of 349.50 due 30 days from today

1 payment of 349.50 due 90 days from today

Please complete the form below

Patient Name

First Name

Last Name

Email

Line

Card Holders

First Name

Last Name

Form of Credit Card

Debit/Credit Card Number

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CVV

Expiration Date

LMREI / Global Administration, INC. accepts the following forms of payment: visa Master card, amex, and discover. I authorize LMREI / Global Administration, INC. to automatically bill as specified.

I agree

Payment Plan Form

Please complete the form below

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