Pay By Credit CardPay By Check or PayPal Patient's Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Blackstone Representative*Select a RepresentativeReceived StatementAaron PelayoAlejandro GuzmanAlejandro MuñozAna BoscanAndres EstupinanAndres HurtadoAndres RomeroAndres PadillaAndres PeñateAngello AcevedoAnthony GomezAnthony RodriguezBryan VasquezCamilo DowCamilo GomezCarolina CastañoCarolyn LopezDaniel CastilloDaniel ZuñigaDaniela MontoyaDarwin RojasDavid CorreaDavid FrancoDavid MachadoDavid LondoñoDavid TorresDeyanery PinoEnzo RamirezEvelhen TobonFabian BravoFabianna JulioFelipe GrisalesFerney SepulvedaHaniel BeckerHenry CuervoHugo ToncelIsabella MuñozJan PribylJessica GarciaJeronimo GarnicaJhoan ZapataJhomberth MoraJhostin ZambranoJohn ZapataJonathan PalemoJorge RuizJorman PayaresJhostin ZambranoJuan CanoJuan BarrientosJuan GuerraJuan MarulandaJuan PardoJuan ParejaJuan SotoJulian GarciaKevin ChavarriaKevin VillarragaKevin PradaLuis UrbinaLuz BarreraManuel BejaranoMarcela SernaMaria ColoradoMaria PelaezMarilyn LassoMariana LopezMateo BedoyaMateo QuinteroMatthew ZarateMichelle MendezMichelle OsepaMiguel FerrerMiguel RamirezNatalia JimenezNicolas CarlosNicolas VergaraOriana MartinezOswald LopezPaula GarciaRuddy ChirinosSamuel DuqueSantiago EcheverriSantiago GuarinSantiago MartinezSantiago MoralesSantiago PastorSantiago PeñaSantiago PintoSebastian LemusSimon ZapataSolangie OrozcoStiven GutierrezValentina GomezValentina MoralesValentina SierraVicente JaramilloWendy ArrietaYan QuintoYerlingheis TamayoYohany SierraYolifran CarrilloWho helped you with this transaction.Amount* Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name CAPTCHA