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             .......... Payment Screen ..........            
Credit Card Number
no spaces or hyphens
Expiration Date
month and year. 		Month     Year
    
Credit Card Code
Click on Image for a Larger Image.
The code is usually 3 digits (rarely 4).
On most cards it is on the back.
On American Express, it is on the front.
Payment Amount
Boxes may be clicked
on and off as needed.
$ 
Amount to Charge Card:
[Enter dollar amount or check test box(s) below]
(001)   
Products of Conception, First Trimester
(002)   
Singleton Placenta, Second Trimester
(003)   
Singleton Placenta, Third Trimester
(004)   
Singleton Placenta, Third Trimester, 4 quadrant exam
(005)   
Twin Placenta
(006)   
Triplet Placenta
(007)   
Fetus - gestation of less than 20 weeks
(008) 
   
 
 
Fetus - gestation of 20 weeks or more
  - Price varialbe (call for quote).
  - Requires autopsy permit (by state law)
  - Autopsy permits at Path-consults.com

Sub-Total:          
Special Studies   (s01)    Karyotype        

  (s02)    Immunostain      p53      p57

  (s03)    Ploidy by FISH     
      This sudy uses one probe. If positive for triploidy, a reflex test using 2 additional
      probes will be done to distinguish from trisomy (additional fees apply).
 

Sub-Total:          
Total of
Current Charges:
Total Charges:            

        

These charges may not be final charges.
If additional testing is required, you will be consulted prior to additional tests being done or fees being charged.
 

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BILLING ADDRESS:
First Name
as on cred. card
Last Name
as on cred. card
Company Name
Street Address
(Billing address where the credit card statements go.)
City
State or Province
   
Zip Code
Country
( Online service for US and
Canada; other countries
should inquire by email)
   
Account ID Number
The ID we gave you.
First time users put 00000 (5 zeros).
Invoice Number
( Leave entry as NA)
SHIPPING ADDRESS:
Same as billing addr
may click on-off
First Name
Last Name
Company Name
Street Addr. or P.O.Box    
City
State
   
Zip Code
Country
   
Purchase Order Number
State Tax
( included in price)
Tax Exempt Status
A tax exempt status will
print "true" in the box.
Not exempt will print "false".
   
    
 

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