Cosmetic Dentistry, Racine Dental Group of Racine, Wisconsin

You can now pay your RDG bill online via our secure payment site. Please gather your account information from a current statement or if you'd like to make a payment without a statement, proceed by filling in the blanks, and click on MAKE PAYMENT. We will send you a confirmation via return email once the information has been processed. If you have any questions, please call our patient accounts department at 262-833-2000.

For other payment options.. see Financing.

* Indicates required information

Patient Name*

Address*

City*

State

Zip*

Home Phone*

Work Phone

E-mail*

(once we have run your credit card we will email you a confirmation)

Account #*

Doctor of Record

Invoice Total*

Amount Paying*

Credit Card Information

Name as it appears on Credit Card*

Card Type*

Card Number*

Card Expiration*

Card Security Code*

(this is the last 3 digits on the reverse of your card)

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