MAKE AN APPOINTMENT
801-313-1010
HOME
OUR STAFF
SKIN CARE AND TREATMENT
RASHES
SKIN CANCER TREATMENT
ACNE TREATMENTS
ECZEMA TREATMENT
PATIENT FORMS
PAY YOUR BILL
PATIENT PORTAL
CONTACT US
PAY YOUR BILL
Patient's Name
*
First
Last
Phone
*
Email
*
Patient Account Number
*
Payment Amount
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Credit Card
*
Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
Expiration Date
Security Code
Cardholder Name
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.