Aurum Group Payments

"*" indicates required fields

Name*

Email*

Telephone Number*

Customer Number*

Invoice Number (For reference only)

Clinic / Lab Name

Payment Amount*

Credit Card*

American Express

MasterCard

Visa

JCB

Maestro

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address*

Address Line 1 Address Line 2 City Province Postal Code

This field is for validation purposes and should be left unchanged.

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