Online Payment

We are pleased to offer online payments for our patients. To pay your bill, complete the form below. If you have any questions, please call us at 801-407-3002, Monday – Thursday 9AM – 6PM or Friday 9AM – 12PM.

Make a Payment

Full Name(Required)

First Last

Patient Name

(If different than billing name)

First Last

Account Number

Email(Required)

Phone(Required)

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Payment Amount(Required)

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Comment / Memo

CAPTCHA

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