Pre-pay for Your Procedure

Simple, Seamless, and Secure

At Albany Regional Eye Surgery Center, we strive to make our patients’ experience as easy and convenient as possible.

* Required Field

Patient Name*

Date of Birth*(mm/dd/yy)

Surgeon's Name*

Date of Service*(mm/dd/yy)

Pre-Payment Amount* $ Amount to be paid (do not include $ sign)

Procedure (optional)

First Name*

Middle Name

Last Name*

Address*

Address 2

City*

State*

Zip*

Country

Phone Number

Email Address*

A receipt will be sent to this email address.

CVV/CVC Number, Please enter the 4-digit number for American Express, and enter the 3-digit number for all other cards.

Card Type*

Card Number*

CVV/CVC Number*

Exp. Month*

Exp. Year*