Payment Form

[Center]

Please use the fields below to complete your payment transaction. Credit cards only accepted on this website. If you have any questions related to your bill and payment, please call our billing office (714)517–2200

[/center]

First Name:

Last Name:

Billing Address:

Billing City:

Billing State:

Billing Zip Code:

Phone Number:

Email Address:

Payment Method:

Credit Card No:

Expiration Date:

CVV2 Code:

Gateway Account #:

Payment Amount:

Total Payment:

GATEWAY MEDICAL Payment Form

Payment Receipt

Name:
Billing Address:
Billing City:
Billing State:
Zip Code:
Phone Number:
Email Address:
Gateway Account #:
Payment Amount:
Total Amount:
Date of Payment:	May 09, 2025
Authorization Code:
Transaction ID: