DMU Clinic Payment

Please do not use this form for patient account payments. Patient account information may be found in your DMU Chart.

If you have any questions please contact Receivables@dmu.edu.

"*" indicates required fields

Payment Information

Payment Description*

What is this payment for?

Payment Amount*

Payer’s Information

Name*

First Last

Email*

Confirmation and receipt will be emailed to this address.

Address*

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

Credit Card Information

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Total

PRIVACY POLICY: We respect and are committed to protecting your privacy. We do not sell or pass along your personal information to anyone. The information submitted here is securely stored on our servers and used to ensure payment is applied to the correct account. Your full credit card or banking information is not retained. Additional privacy information may be found at www.dmu.edu/legal.

Name

This field is for validation purposes and should be left unchanged.

Payment Information

Payer’s Information

Credit Card Information

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