Let’s Get Started

First Name *

Last Name *

Phone *

Email *

About Your Upcoming Visit

Clinic Name *

Estimated Total Cost *

When is your visit expected?

Monthly Payment Preferences

Which option sounds closest to what you’re looking for?

Monthly card payments (no loan)

Upfront payment + monthly payments

I’m not sure — I’d like guidance

What Happens Next

After you submit this form, AwayMed will review your details and contact you to explain your monthly payment options. Your clinic is paid in full before your visit.

Monthly payments may continue afterward.

I understand that AwayMed is not a medical provider and agree to receive SMS or email messages related to payment coordination.