iContour Payment

Please complete the information below to process a one-time secure ECH or Credit Card payment for your iContour® instrument.

"*" indicates required fields

1Payee Information

2Payment Information

Name*

First Last

Email*

Phone*

Billing Address*

City State

Visionary Optics Account Number*

This should be 4 digits

iContour® Quote/Invoice #*

Pay By*

eCheck

Credit Card

One-Time Payment*

Enter the amount to charge

Please note, the “other amount” payment will be applied to the oldest invoice(s) open on your account.

Detailed Payment Receipt

We will have a member of our staff send you a detailed payment receipt to the email provided within 24 hours.

Yes

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Bank Info*

Name on Account Bank Name Routing Number Account Number Account Type

If you receive an error while processing this payment or need further assistance, please reach out to our Billing Department at 877.533.1509 x5 or billing@visionary-optics.com

One Time Payment Total

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