Patient Notebook

Gainesville Surgery Center

1945 Beverly Road

Gainesville, GA 30501

Phone: (770) 287 - 1500

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Error Summary

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1. Patient Information

First Name *

M.I.

Last Name *

Patient Account Number *

Date of Service

Phone Number *

DOB

Email Address

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2. Payment Amount

Amount

3. Payment Method

Bank Account

Account Type
Checking Savings

Routing Number *

Account Number *

Name On Check

Check Number

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