Payment Page - QMB Inc.


                        Current Date
Who sent you the Statement?*
Patient Name
                            
                                                    
                                                    First
                                               
                            
                                                    
                                                    Last
                                                
                            
                        
Email*
                                
                                    
                                    Enter Email
                                
                                
                                    
                                    Confirm Email
                                
                                
                            
In order to receive an email confirmation.
Same As Patient (Address on Statement)*Yes
No
Address that card was registered under*    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State
                                      
                                    
                                    ZIP Code
                                
                    
                
Have you been at this address for less than 90 days?
								
								Yes
							
Please provide prior address    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State
                                      
                                    
                                    ZIP Code
                                
                    
                
Patient Date of Birth
                            
                        
                        
Account Number
Credit Card Info
Credit Card Number*
Exp Month*
Exp Year*
Security Code*
Name as it appears on Credit Card*
Amount to be paid*
Phone*
Mail Receipt
								
								Yes
							

								
								No