Payment Form

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ADVANCED EYECARE Payment Page

Thank you for visiting our online payment page for all outstanding invoices and purchase orders. Please complete the fields below and submit when done.

Invoice Number

Client/Patient Name

Payment Amount

Cardholder Name Cardholder Email Cardholder Phone

By submitting this payment, I authorize Mirai to send a copy of the receipt(s) to the email address I provided along with a copy to the above referenced merchant. I also understand if there is any other information needed additional emails may be sent on behalf of the merchant from Mirai.