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Online Patient Bill Payment


To pay your Clinica bill please complete the following information.
Card Type  
Card Number:
Card Expiration Date: mmyy
Clinica Account Number
Payment Amount
Patient First Name:
Patient Middle Name (or Initial):
Patient Last Name:
Patient Date of Birth:
The name below must match the name on your credit card.
First Name:
Middle Name (or Initial):
Last Name:
Phone Number
Email Address:
Zip Code:
For Security Please Type Image Characters:

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