Vantage Clinical Solution Payment Form

Customer Details

 I am an existing Vantage client
 I am brand new to Vantage

Payment Details

 I am paying an invoice and have an invoice number
 No invoice number for me

Payment Frequency

 I am making a single, one-time payment
 I would like to setup a series of payments

Billing Information

Credit Card Information

 Please save my payment info for future payments

Cardholder Attestation

I attest that I am the cardholder named above, and that i am authorized to approve this transaction. Upon submission, i understand that my credit card will be charged for the amount entered above.