Henry Fertility Payment Form

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HENRY FERTILITY CENTER FOR REPRODUCTIVE BIOLOGY OF INDIANA

Henry Fertility Payment Form
201 Pennsylvania Parkway, Suite 325

Indianapolis, IN 46280

317-817-1800
4 Digit Account # *
The account number can be found on your bill or on the bottom of an emailed cycle quote. If you can't find it, please send a request email to info@henryfertility.com
PATIENT INFORMATION

(Please Enter the PATIENT information here)
NOTE: PLEASE ENTER THE NAME OF THE PATIENT & THE PATIENT'S DATE OF BIRTH BELOW (Not the name of the person paying the invoice).
Patient Name *

PATIENT- First Name PATIENT - Last Name
Patient Date of Birth *
PATIENT - Date of Birth

Patient Address *

Payment Amount *

USD Please enter the full amount you are paying.

Terms of service:

All sales are in U.S. Dollars. All Sales are final. If your card is declined, it may be due to a daily limit set up by your bank, or if an HSA card is used, your HSA may reject it due to not recognizing the vendor.
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PLEASE REVIEW YOUR INVOICE OR STATEMENT