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Appointment Fee

Thank you for applying to become part of the Kaleida Health Medical/Dental Staff. As a convenience, you may pay your non-refundable appointment fee using any major credit card. Please complete the following information to finalize your application process.

Appointment Information
Please enter the Provider's Name
Please enter the Provider's NPI Number
Please enter the Provider's License Number
Contact/Billing Information
Salutation
Please enter contact's First Name
Please enter contact's Last Name
Please enter contact's Company
Please enter contact's street address
Please enter your City
Please enter contact's State/Province
Please enter contact's Zip Code
Please enter contact's Phone Number
Please enter contact's Email Address
Payment Details

Appointment Fee: $300

Please provide a valid credit card number
Please select a valid expiration date
Please provide a valid 3 or 4 digit csn located on the