Payer Information
Enter the information of the person making the payment.
First Name
*
Middle Name
Last Name
*
Email Address
*
Your payment confirmation and transaction reference will be sent to this email.
Contact Number
*
11-digit mobile number, e.g. 09171234567.
Patient Information
Enter the patient details associated with this payment.
Patient ID
*
First Name
*
Middle Name
Last Name
*
Payment Details
Specify the purpose and amount of your payment.
Particulars
Maximum of 100 characters.
Amount (PHP)
*
Select Payment Method
Choose one available payment option.
GCash
GrabPay
Maya (PayMaya)
BillEase
QR Ph
Credit / Debit Card
Card Information
← Change payment method
Card Number
*
Expiry Month
*
MM
01
02
03
04
05
06
07
08
09
10
11
12
Expiry Year
*
YYYY
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
CVC
*
