• PLEASE REVIEW YOUR INVOICE OR STATEMENT

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  • Henry Fertility Payment Form

  • 201 Pennsylvania Parkway, Suite 325

    Indianapolis, IN 46280

    317-817-1800

  • 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).

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  • PAYOR INFORMATION

    (Name and information for the person paying the invoice)
  • NOTE: ENTER THE FULL NAME ON THE CREDIT CARD.

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    Billing Address
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  • 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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