Dr. Virro Accounting

FOR MARKHAM FERTILITY CENTRE PAYMENTS ONLY – Please check the top of your invoice to ensure it states “Markham Fertility Centre.” This does not include Dr. Dzineku, Dr. Garcia, Dr. Pyselman, Dr. Roth, Dr. Roumain, Dr. Virro or Dr. Wais invoices.

Invoice Number :*

Patient's First Name :*

Patient's Last Name :*

Partner’s First Name (If Applicable) :

Partner’s Last Name (If Applicable) :

Personal Email :*

Phone Number :*

Address*

Street Address City Province/Territory/State Postal Code/Zip Code Country

For secure VISA, MasterCard or AMEX payment please complete the following;

Amount :

Credit Card Details

Card Details

Cardholder Name

Name

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