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17205M SCHS Online Pymts
1441 Crossways Blvd
Chesapeake,VA 23320
(757) 388-2900

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt
Payment Type

           
Credit Card Bank Account


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Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
Add Row Total $0.00
Student Last Name
Student First Name  Middle :
  (MM/DD/YYYY)
Primary Phone #  -  - 
Email
Payment Type
       Zip    -
Program

Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
CVN   What is this?
Amount            Current Balance  
Save this card for future use

Account Information

       Account Holder Zip    -
Account Holder Zip    -
Account Holder Phone #  -  - 
  Your credit card/bank account will not be charged
until all information is confirmed in the next step.
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