Pay Online

To make an online payment, complete the form below.

Payment Details

To make an online payment, complete the form below.

Payment Details

Patient Name*

Account Number*

Amount*

Billing Information

Please provide your billing information.

First Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Payment Information

Card Type*

Card Number*

CVV Code*

Name on Card*

Expiration*

I hereby authorize my bank to deduct from my bank account this one-time payment of my
Nicholson Clinc bill as indicated above. Nicholson Clinc will note this transaction on my account until funds are secured from my banking institution. In the event
Nicholson Clinc is unable to secure funds from your bank account for this transaction for any reason, including but not limited to, insufficient funds in your account or insufficient or inaccurate information provided by you when you submit your electronic payment, further collection action may be undertaken by
Nicholson Clinc including application of returned check fees to the extent permitted by law.

AGREEMENT:
By clicking 'Submit,' you are agreeing to the above Terms & Conditions.