MAKE A PAYMENT

Midwest Dermatology accepts payments via credit cards online. Simply fill out the patient details below and select the Make Payment button to continue.
 
Payments will be processed through our Authorize.net secure online payment processor. Once you enter data, it will immediately be submitted over HTTPS (secure and encrypted) to Authorize.net. Data is not collected on the Midwest Dermatology Clinic website and this process assures confidentiality and is HIPAA compliant.
Account Number
Patient Name
Date of Birth
MM / DD / YYYY
Phone Number
Payment Amount
Example: 100.00
All information submitted to Midwest Dermatology Clinic, P.C. will be held in the strictest confidence. The information provided above will be used for internal business only and will not be sold or targeted for marketing purposes.