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
Henry Fertility 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.
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PLEASE REVIEW YOUR INVOICE OR STATEMENT