Kapolei Walmart Payment Form

Name: Pearl City Sam’s Club
Address: 1000 Kamehameha Highway, Suite 100, Pearl City, HI, 96782, US
Telephone: 808.456.3937
Price range: $000 - $300

This form is for patients to pay Hawaii Vision Associates through Authorize.net

Patient's Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
What is this payment for?*
- Exam Copayment
- Balance on the Account
Invoice #
Amount Due*
Payment Amount*
Billing Address for the cardholder*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cardholder's Phone Number*
Cardholder's Email Address*
Payment Type*
- Credit Card
- Debit Card
Credit/Debit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name