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{{patientName}} Amount : {{patientDue}}

{{nexioHeadertext}}

Enter Amount

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Adaptamed Interface for Nexio Payment Gateway

Name :

Need To Assign

Date :

01/01/1900 00:00:00

Card Num :

****

Response Code :

0

Auth Code :

0000

Invoice :

00-0000

Customer ID :

0-0000

Amount :

$0.00

I AGREE TO PAY ABOVE TOTAL AMOUNT
ACCORDING TO CARD ISSUER AGREEMENT