FORT LAUDERDALE:  5333 N. Dixie Hwy. Ste 204 Fort Lauderdale, FL 33334
BOCA RATON: 500 NE Spanish River Blvd. Suite 35 Boca Raton, FL 33431
FT. LAUDERDALE: 954-776-7566
BOCA RATON: 561-220-0450

PAYMENTS

In order to process your payment online, please fill the following form and with the patient information. Once you click submit you will have the option to pay with PayPal or credit card. Your information is safe, the form results are sent securely with SSL encryption.

PATIENT'S FIRST NAME (required)

PATIENT'S LAST NAME (required)

PATIENT'S DATE OF BIRTH

DATE OF SERVICE

CONTACT PERSON'S EMAIL (required)
Email address of the person making the payment

CONTACT PERSON'S NAME
Name of the person making the payment (as shown on credit card)

SERVICE
Please select one or multiple services from the following list. Prescription drugs require a valid prescription on file in our office before any order can be processed. For any questions please contact our office: (954) 776 7566

1. Initial Office Visit A $104.002. Initial Office Visit B $175.003. Initial Office Visit C $205.004. Initial Office Visit D $230.005. Follow Up Visit A $80.005. Follow Up Visit B $105.006. Follow Up Visit C $165.007. Laboratory Blood Test CBC w/ Diff/ Chemistry 25/ Sed Rate $130.008. Laboratory Blood Test CBC w/ Diff/ Chemistry 25 Only $110.009. Lab. Blood Test Testosterone Free/ Testosterone Total/ PSA $150.0010. Lab. Blood Test Testosterone Free/ Testosterone Total Only $100.0011. Laboratory Blood Test Hepatitis ABC $175.0012. Laboratory Blood Test Rheumatoid Arthritis Panel $70.0013. Laboratory Blood Test Thyroid Profile w/ TSH $70.0014. Urine Drug Screen $30.0015. Urine Drug Screen & Urine Analysis $30.0016. X-Ray $100.0017. EKG $50.0018. Injections B12 $10.0019. Injections Testosterone 1/2cc $20.0020. Injections Testosterone 3/4cc $25.0021. Injections Testosterone 1cc $30.0022. Injections Trigger Point $75.0023. Injections Cortisone $75.0024. No Show Fee $20.0025. One Week Office Visit $55.0026. Certified Mail Script $10.00

COMMENTS / MESSAGE

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