Payment A 50% non-refundable deposit is required at the time of booking to reserve your appointment. The full balance must be paid 2 weeks prior to your surgery date. Deposits and payments are non-refundable. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.ENTER AMOUNT *Authorize.Net *Card NumberMM123456789101112Expiration/YY2425262728293031323334Security CodeAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDisclaimer *Upon authorization of payment, I agree that I have read, acknowlege, understand and agree with all client forms from client page LCC website.Submit