Index

This Payment Site is for Patients of William Samson MD with service AFTER 7/1/2021.

If your DATE OF SERVICE is AFTER JULY 1, 2021 please submit your payment here.
Statement Information
Patient First Name
Patient Last Name
Account Number (Enter account numbers that follow the letter code)
Amount To Charge Today $
Billing Information
Credit Card Number
Security Code
Expiration
Name on Card
Billing Zip
Send me a receipt to my email.
Email Address