To pay by credit card please complete the form below:
Name *
Name
Billing Address *
Billing Address
$
Expiration Date
Expiration Date
By clicking 'Submit' below, I authoize Wilkerson PC to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card.