Patient Information

*  Patient's First Name
*  Patient's Last Name
*  Patient's Date of Birth    
*  Account Number


Cardholder/Payment Information

credit cards accepted: Mastercard / Visa / Discover
*  Name on Card
*  Address
*  City
*  State
*  Zip Code
  Email Address

(Optional: A verification of payment will be sent to the email address if entered. Your email address will not be used for any other purpose than to send a payment confirmation.)
*  Daytime phone number (area code first)
*  Amount of Payment $
(Please enter dollar and cents. Ex. 10.26 )
*  Credit Card Number
*  Card Security Number What is my card security number?
*  Credit Card Expiration  
*  Indicates a required field You must make multiple payments if you
have more than one account.

Thank you for using our online system. Please be aware that payment processing may take up to 5 days.

Refund Policy: If a payment made on this site results in an overpayment of the patient's liability for services rendered, Wake Forest Baptist Health will issue a refund to the appropriate payee by check.

Privacy Statement: Click here

Please contact 336-716-3988. if you have any questions or concerns regarding your payment.