["ccnumber","ccexp"]
"hide"

"https:\/\/quickclick.com\/cart\/security.php"
Secure Transaction
Billing Information
First Name:
Last Name:
Address:
City:
State/Province:
Zip/Postal Code:
Phone Number:
Email Address:

Additional Information
ACCOUNT(S) #: Only one payment transaction required for multiple accounts:
PATIENT'S NAME (If different than above):
CLIENT # (If paying a provider bill):