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 *

PATIENT - Street Address

PATIENT - Street Address Line 2

PATIENT - City PATIENT - State / Province

PATIENT - Postal / Zip Code PATIENT - Country
Patient Phone Number *

PATIENT - Area Code PATIENT - Phone Number
Patient E-mail *
Has your contact information changed? *

Yes (If so, please note below) No
Notes:
ex: This payment is for my current cycle of treatment.
PAYOR INFORMATION

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

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.
Enter the message as it's shown *
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PLEASE REVIEW YOUR INVOICE OR STATEMENT