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Payment for Services

For your convenience, we will accept payment for services ONLY on the day of the actual procedure, not on the 1st visit because of the Arkansas State mandated 72-hour waiting period. We cannot accept payment in advance of any scheduled abortion appointments according to the State of Arkansas abortion laws. If you erroneously, pay in advance of the actual day of the abortion procedure, you will be refunded the full amount. Thank you.

Today's Date(Required)

Time(Required)

Patient's Full Name(Required)

First Last

Phone(Required)

Patient's Email(Required)

Patient's Date of Birth(Required)

CARDHOLDER INFORMATION

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Statement Address(Required)

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

Cardholder's Email for Receipt(Required)

Driver's License Number(Required)

Driver's License State(Required)

Enter Amount You're Paying(Required)

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