Mary S. Frank, M.D.
810 Kentucky St
Lawrence, KS  66044
Office: (785) 331-2000
Fax: (785) 331-2001
Billing: (913) 912-3095


To make a payment by Credit Card please contact our office or fill out the information below:


Name of Patient:

Type of Card:      Visa      Mastercard      American Express     Discover     Other

Name on card:

Credit Card Number:

Expiration Date:			CVV Code:
						(3 digit number on front of MC, Visa or Discover)
						(4 digit number on back of American Express)

Billing Address: 
(Address where you receive your credit card bill)

City:	 		State: 		Zip:



Amount of Payment: 

Recurring:    One Time Payment	  Every Session		Other:
			   






Date: