Birmingham Wellness Center Secure Online Payments

Payment Information
Payment Amount

Contact
First Name*
Last Name*
Email*
Verify Email*
Phone*

Billing Address
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

*Required

I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Birmingham Wellness Center Terms as referenced in the [Terms of Use] link below.

Thank you so much for your business!

Birmingham Wellness Center
34100 Woodward Ave, Ste 100 Birmingham, MI 48009-0962
(248) 645-6070

To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.