If you are a patient of Dr. Rubinstein's, you can pay all or part of your bill online by filling out the form below.

If you are a new patient, and you would like to reserve an appointment for a surgical operation, you can make your pre-surgical deposit by filling out the form below.

I am a current patient who wishes to pay all or part of my bill

Invoice number on bill:

I wish to pay my entire bill at this time
I wish to pay part of my bill (Enter Amount: )

I am a new patient and I would like to make a deposit of $100.00 to reserve an appointment for a surgical operation.  (A member of our staff will contact you to schedule a time for the appointment).

Patient Information:

Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email:

 

Payment Information:

Credit Card Number:
Expiration Date:
Name as it appears on the credit card:

Comments:

By pressing the Submit button you authorize Dr. Rubinstein to charge your credit card for the amount listed above.