Online Payment

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By checking this box you are authorizing Des Moines Eye Surgeons to charge your Debit/Credit card for the amount you have indicated. Your card will be charged within 48 hours of submitting this form. The charge on your statement will appear as “DMEYESURGEONS”. Please call (515) 225-1206 with any questions.
(*)I agree to the terms
Debit/Credit Card

(As it appears on the card)

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