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Online Payment

You may submit an online payment by completing the form below. You will be redirected to the payment site where you may submit payment with most major credit cards.

If you would like to set up automatic payments of your copayments, deductibles and session fees, please download the automatic debit authorization form, complete and mail it to my office. I must have the original, signed form to set up automatic debits.


Payment for Physician Services

Amount to Charge: $

Account or Patient Name:

Name on Card:

Address (1st line):

City: Zip code:




copyright 2009 Thomas A Grugle, MD. All rights reserved.

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