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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

$0.00

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 *