70-31A 108th  Street
Suite# 10
Forest Hills, NY 11375

 

 Phone: 718-575-2200

Fax: 718-575-2206

Payment Form

Patient Full Name*

First Name* Last Name*

A to Z Pediatrics Account Number*


Billing Address



Street Address*


Address Line 2

City* State*


Zip*


Phone

Email*


Date of Service*

(Date format:mm/dd/yyyy)


Payment Information*



Card Number*

Expiration (MM/YYYY) CVC*


Card Holder Name*

Payment Amount*