Make an online payment

Your invoice details

Your payment details

Receipt

To pay for treatments at Blaise Referrals, please visit their website.

Select a Clinic from the options below*

Case ID (This can be found on your invoice)*

Please ensure this is no longer than 7 digits

Amount to pay (e.g. 10.99)*

First Name*

Last Name*

Patients' Names

Email*

We'll only use this email address to send you a confirmation of your payment

Contact Number

We'll only use this number in the case there is a problem with your payment