New Patient Billing Form – Frontline Health Advocates | Medical Exemptions for Vaccines and Masks

Secure Billing Form

Patient Name(s)(Required)

Patient E-Mail(Required)

Medical Exemption (8 Business Day Completion)

Price: $495.00

2 Business Day Expedite Per Exemption

Price: $200.00

Next Business Day Expedite Per Exemption

Price: $300.00

Patient Provided School / Employer Form (office approval required)

Price: $100.00

Other Administrative Services

Price: $50.00

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type

Total

Credit Card Billing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name