Make A Payment – ColonoscopyAssist

Referral Code
If you have received a Referral Code from a friend, family or physician, enter it here.
Total
$0.00
Patient Name*
First Last
Patient ID*
Your patient ID can be found in any email communication received from ColonoscopyAssist. Please ensure this number is accurate as it is used to assign the payment to your account.
Consult or Procedure Date
If you are unsure, please leave blank
Email*
Please be careful when entering your email. Payment confirmation receipt will be sent to this email address only. We can no send a copy to an alternate email address at a later date.
Comments / Notes
Please use this field to include any additional notes for us
Billing Address*
Street Address Address Line 2 City State Zip Code
Did you know?
On average, it costs our program approx $20 to accept a credit card but only $1 to accept a debit card. Please help keep costs low by using a debit card.
Debit / Credit Card
ColonoscopyAssist does not accept AMEX at this time.

Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Total Amount
$0.00
I authorize ColonoscopyAssist to charge my card for the amount above
Signature*
Cardholder Name*
Please re-enter cardholder name
First Last
It make take up to 60 seconds for this form submit. Please do not press the back button. If the form is succefully submitted, you will receive an email confirmation.