NorthStar VETS Payment Terminal

Pay by Card

Payment Information

Type of Payment*

Other

Location*

Invoice Number

Amount*

Patient Information

E-mail:*

Phone*

Patient ID

Patient Name

Owner Information

First Name:*

Last Name:*

Address:*

City:*

State/Province:*

ZIP/Postal Code:*

Credit Card Information

Card Number:*

Name on Card:*

Exp. Date:*

CVV:*