Payments | Western Surgical Group

You may securely make a payment here for your Western Surgical or Western Bariatric Institute account. Upon approval, a receipt will be emailed to you and your payment will be posted to your account within 2 business days. No Refunds on Account Payments, except in the case of overpayment, then a credit will be issued to your Credit Card. Information is used expressly for payment processing only.

Note: All fields are required!

Patient Information

Name*

First Last

Account #*

Phone #*

Credit Card Billing Information

Name*

First Last

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code

Email Address*

Payment Amount*

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Name

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