Fee Payment Name* First Last SAU ID Email* Treatment ListNoneAllergy Shot - $3Blood Sugar Check - $3Flu Injection (Spouse) - $15Mono Test - $4Pregnancy Test - $2Sickle Cell Test - $13Strep Test - $5Suture Removal - $7TB Skin Test - $10TDAP Vaccine - $35T-Spot - $65Updraft Treatment - $6 w/ TubingUpdraft Treatment without Tubing - $3MMR Vaccine - $70Custom Fee Amount Use this field to enter the total for multiple treatments or a fee not listed above. Total $0.00 Credit Card* DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name HiddenDate HiddenTransaction ID HiddenCode HiddenDescription HiddenDate
