- Corduro Pay

Personal Information

First Name: *

Last Name: *

Company:

Address: *

Apt/Suite No.:

City: *

Country: *

State: *

Zip Code: *

Email: *

Phone:

Other Information

If payment applies to more than one practitioner, please list full names here.

Notes: *

Medical Staff Dues: July 1, 2024 - June 30, 2025.

Suggested Amounts

$

Amount:

$

Additional Amount

$

Appreciation Gift

Convenience Fee

$

Total Amount

$

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Card Holder: *

Card Number: *

Expiration: *

Security Code: *

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