We accept MasterCard, Visa, Discover, and American Express.

Xytex provides this payment form as a secure way to provide payment information via the internet through a secure SSL encrypted connection. You may verify our SSL certificate by clicking on the TrustWave seal just to the left of this statement. The information you submit on this form is used to process your payment once your order is complete. Submitting this form does not charge your card in real time and does not guarantee your payment will be approved. All orders are confirmed by email or phone prior to charging your card.

* required fields
 
 
1. Order Information
 
* Order Number:   
 
Amount of Payment (in US dollars):  $ (leave this field blank if you're not sure)
 
* Your Name:    (list it as it is on file at your clinic)
 
Patient Birth Date:    (please enter in format month/day/year)
 
* Your Email Address:   
 
* Retype Your Email Address:   
 
 
2. Billing Information
 
* Address:   
 
* City:   
 
* State:   
 
Other State/Province:
* required if outside the US
  
 
* Zip Code:   
 
* Country:   
 
 
3. Card Information
 
* Card Type:   
 
* Name on Card:   
 
* Card Security Code:   
 
* Card Number:   
 
* Expiration Date: