Payment Test - StreamDent - The Streamlined Practice

I would like to make a payment to:

StreamDent^®
303 South Main Cross St.
PO Box 474 Flemingsburg, KY USA
Phone: (502) 509-1570
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One-time Payment (Single Payment)
One-time Payment Amount in US Dollars.*
Total
$0.00
Purpose*
Description or Comments:
Billing Information:
Dental Office*
Full Name*
First Last
Phone*
Email*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
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