Patient Notebook

Patient Information

First Name *

M.I.

Last Name *

Account *

Invoice #

Invoice Date *

Email Address

A receipt will be sent to this email address.

Payment Information

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Amount is required.

Installment Amount must be equal to or greater than the Minimum Installment Amount shown.

Installment Amount exceeds the Plan Balance.

You cannot set up a payment plan without submitting a valid email address.

First Payment Date is required.

Payment plans must start today or later.

Payment plans must start within one year.

First Payment Date is invalid.

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One-time Payment

Amount *

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Credit/Debit Card

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Name on Card *

Card Number *

Expiration Date *

Security Code *

Zip Code *

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Southern Utah Ear Nose and Throat

617 E Riverside Dr

Saint George, UT 84790

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