Pay Your Bill Online - Seattle Fertility

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PATIENT INFORMATION

For all international billing, please select "International" in the state dropdown and input "98109" for zip code.

Patient First Name:

Patient Last Name:

Patient Date of Birth:

Patient Account #:

Patient eMail Address:

Patient Billing Address:

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Zip:

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CARD HOLDER INFORMATION

SAME AS PATIENT

Card Holder First Name:

Card Holder Last Name:

Email Address for Receipt:

Card Holder Billing Address:

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Zip:

Contact Phone Number:

REASON FOR PAYMENT

Payment on Account Balance

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Charge will appear as SRM – eCommerce on your Billing Statement