Directory Search – Partners in Healthcare

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Item

Quantity

Unit Price

Subtotal

Billing Information

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Full Name

Company

Title

Clinical Designation

Email

Phone

Fax

Address

City

State

Zip

Payment Method

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Pay with Debit or Credit Card

Name on Card

Card Type

Card #

Expiration Date

CCV #

Format: MM/YY or MM/YYYY

Pay with Electronic Check

Bank Name

i.e. Bank of America

Account Type

Checking, Business Checking or Savings

Account Number

Usually 15-20 digits

Routing Number

9 digits

Pay with Paper Check

Don't forget to submit your transaction
by pressing the submit button.

Please mail a check in the amount of price unavailable to:

Partners in Healthcare of Virginia
P.O. Box 29604
Richmond, VA 23242

Important: In the Memo/For section of your check, please write: .

After we have received your check, you will be notified and your account will be updated with the items you've purchased.