Park Allergy Center Telemedicine System

Park Allergy Center Account Number Enter a valid Park Allergy Center Account number

Patient Name Patient Name

Patient Email or Mobile Phone (This is where we send your reciept) Patient Email or Mobile Phone (This is where we send your receipt)

Patient Date of Birth Enter Patients Date of Birth

Amount Due (enter in dollars and cents example 5.00) Amount Due

Card Type

Visa

Mastercard

Discover

Card number Enter a valid 12 to 16 digit card number

Name On Card Please enter the name found on the front of your card

Expiration Enter the expiration date

CVV

Enter the 3-digit code on back

Zip code

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