SNU Student Health
Patient First Name
(Required)
Patient Last Name
(Required)
Email Address
(Required)
(Invalid Email)
Credit Card Information
Cardholder First Name
(Required)
Cardholder Last Name
(Required)
Card Number
(Required)
(Invalid)
Expiration Month
01
02
03
04
05
06
07
08
09
10
11
12
Expiration Year
25
26
27
28
29
30
31
32
33
34
Card Security Code
(Required)
(Invalid)
Amount
(Required)
(Invalid)
We Accept
NOTE: A processing fee equal to 2.25% of the payment amount will automatically be added to the amount charged.
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2025
SNU, All Rights Reserved.
Forms by: SNU IT
