Pearl City Sam’s Club Payment Form

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

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

Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name