Make a Payment Steele Dermatology Payments If you would like to make a payment online, please fill out the form below. If you have questions about payments or your bill, please call our office at (770) 464-6000. By entering your credit card information and submitting this form you are stating that you are an authorized user of the credit card and that the associated information (account holder name, account number, billing address, etc.) is accurate and that you authorize Steele Dermatology to charge the amount you have requested to your credit card. If after you submit your credit card payment via the online payment tool you feel that you made a payment in error, please contact our office at (770) 464-6000 and we will be able to assist you with any requests or questions you may have. All information that you provide on the credit card payment forms will be handled in accordance with all federal regulations. Name* First Last Patient Name* First Last Patient Date of Birth* MM DD YYYY Email* Phone*Payment Amount* Invoice Number*This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Questions, Comments, Or Special InstructionsTotal $0.00 This iframe contains the logic required to handle Ajax powered Gravity Forms.