Online Payments Online Payments Name* First Last Date of birth: Mobile phone number:* Email* Appointment date:* Appointment time: Payment for:*Telehealth consultationOffice based consultationSurgical procedureAssistant feeOther (Please specify below)Other: Invoice number: (If provided) Fee Total $ 0.00 Payment method: Credit Card (Stripe) Paypal (nb. you will be redirected to Paypal when 'submit' is pressed) Credit CardCard Details Cardholder Name
