Patient Payment Form Your InformationName(Required) First Last State(Required)Select your state...FloridaTennesseePhone(Required)Email(Required) Billing Address(Required) Street Address Address Line 2 City Select your state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping AddressAddress Line 1(Required) Address Line 2 City(Required) State(Required)Select your state...FloridaTennesseeZip Code(Required) Prescription DetailsPrescription #(Required) Payment Amount(Required) Please only submit the amount you were quoted. Our Billing department will reach out if there are any discrepancies.Credit Card Information(Required)Card Details Cardholder Name Please contact us at 727-240-1341 if you have any questionsCommentsThis field is for validation purposes and should be left unchanged.