Patient Notebook

Patient Information

First Name *

M.I.

Last Name *

Account Number *

Email Address *

A receipt will be sent to this email address.

Payment Information

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Amount is required.

Installment Amount must be equal to or greater than the Minimum Installment Amount shown.

Installment Amount exceeds the Plan Balance.

You cannot set up a payment plan without submitting a valid email address.

First Payment Date is required.

Payment plans must start today or later.

Payment plans must start within one year.

First Payment Date is invalid.

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One-time Payment

Amount *

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Name on Card

Card Number *

Expiration Date *

Security Code *

Zip Code *

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Qoros Clear Lake Surgery Center

1240 Clear Lake City Blvd STE 100

Houston, TX 77062

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