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Latest News
Now hiring - FT Certified Medical Assistant!

Free Camp for Kids with Asthma


 
 

Vaccine Study Information
Click here for information on Vaccine Studies in conjunction with University of Md.


 

Questions about Lyme Disease?
We're getting a lot of calls about Lyme Disease. Click here for more information.

 

Online Billing

All fields with an * must be filled out for the payment to be processed.

Credit Card payments are not online transactions, only submissions. They are processed in our office within 3 buisiness days and credited to your account. If you would like a receipt mailed to you, please indicate this in the comments field.

Information
*Parent Name:
First Last

*Child's Name:
First Last

*Child's Date of Birth:
Month: Day: Year:

*Acount Number:

*Phone #:

*Email Address:

Payment
*Amount: $

*Billing Address:

*City: *State: *Zip:

*Name on Card:

*Credit Card Type:

*Credit Card #:

*CVV2 Number:
This is the 3-digit code is located on the back of your card, inside the signature area. Typically the signature panel will have a series of numbers, but only the last three digits make up the CVV2 code.

*Expiration Date:
Month: Year:

Comments:

 

All information submitted with this form is secured to The Pediatric Center with 128-bit encryption.

 

 

  1475 Taney Avenue | Frederick, MD 21702 | phone 301.662.0133 | fax 301.695.8604 | © 2007