payment processing

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

First Name:
Last Name:
Account number:
Phone number:


Credit Card Billing Information

First Name:
Last Name:
Billing Address:
City:
State:
Zip:
Email Address (for payment receipt):
Payment Amount $: