Bayshore Diabetes Libre Internal Payment
Full Name on the Credit Card
Card Number
*
CVV
*
Expiry
*
The Amount Paying Today
Patient ID#
Billing Province
*
Select from list
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
Agent Email
Does the customer want to be on the Subscribe and Save Program:
The Bayshore customer would like to join the Subscribe and Save Program.
They have confirmed that they understand they no longer need to call or go online to place their orders.
They agree to have Bayshore automatically ship and bill the credit card being used today for future orders.
They understand they can cancel - by calling between the hours of 8am - 8pm - Monday through Friday to cancel
Yes
No
Processing Payment ...
Pay
Cancel