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In-House Payment Form

In House Payment Processing ONLY

Order Number *

First Name *

Last Name *

Email *

Email address where you would like payment confirmation sent.

Number of Test Kit packages ordered

Payment Information

Payment amount

Total

Credit Card Billing Information

(please enter as information appears on your credit card). Visa and MasterCard only.

Name *

Address Line 1 *

Address Line 2

City *

Province *

Postal Code *

Credit Card *