I, [firstName] [lastName], authorize the use of my credit card as described below (name as is appears on card) for charges related to the services provided by Fivestar Pulmonary Associates. This card may be used to pay for services rendered to [firstName] [lastName].
Please submit this form to confirm your payment and show proof of payment to the front desk (or email to office@fivestarpulm.com).
The payment link below will bring you to the Square website to provide a secure method of payment.