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Washington Center For Rehab
4573 Route 40 • Argyle, NY 12809-3474
Personal Information
Full Name
*
Address
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Phone Number
Email Address
*
Transaction Details
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Amount
*
+ Convenience fee: 3%
on
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Residents Name
*
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*
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Credit Card Details
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*
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By clicking this form, you give Washington Center For Rehab permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
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Washington Center For Rehab
4573 Route 40
Argyle, NY 12809-3474
Tell: 518-638-8274
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
