Payment Page

NOTE: All fields with a red asterisk (*) are required in order to process your payment.

If you have any problems with this page, please call the PVH Patient Billing office at 207-794-7194.

Acct Number or Note

Card Number

Expiration Date

Security Code (CVV)

NOTE/MEMO:

First Name

Last Name

Address 1

Address 2

City

State

Zip/Postal Code

Country

Email Address

Phone #

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