Payment Portal

Please complete the form below to send a payment to Advanced DDS or Advanced Children’s Dentistry using our secure, encrypted credit card processing. After your payment is completed, you’ll receive an email at the address entered on the form, confirming the information you submitted.

ABOUT THE PATIENT
Patient's Name*
First Last
Patient Account Number
Patient Date of Birth
Patient Home Phone
Patient's Email
Are you the Patient or the Payor?
- Patient
- Payor
PAYOR INFORMATION
Payor's Name
First Last
Relationship
Payor's Phone Number
Payor's Email
PAYMENT INFORMATION
Please apply this payment toward my*
- Account Balance
- Prepayment
Select the Practice for your payment*
- Advanced DDS
- Advanced Children's Dentistry
Enter the amount you are paying today
Credit Card Billing Address*
Street Address Address Line 2 City State ZIP Code
Do you have a file to upload?
- Yes, I have a file to upload
Upload a file
Drop files here or

Accepted file types: jpg, png, bmp, pdf, doc, docx, xls, xlsx, txt, Max. file size: 2 MB, Max. files: 4.
You can upload up to 4 files totaling 2MB. Acceptable file types are jpg, png, bmp, pdf, doc, docx,xls, xlsx and txt.
Anything else we should know?
Email
This field is for validation purposes and should be left unchanged.

Payment Portal

ABOUT THE PATIENT

PAYOR INFORMATION

PAYMENT INFORMATION

To Make A CareCredit Payment, Click The "Pay Now" Button Below:

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