BRIJ HEALTH
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Brij Health | Bill Pay
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Agency/Company
(Required)
Service Pricing
(Required)
Virtual Appt
TB Skin Test (Placement and reading)
TB Blood Test Orders
Chest Xray Orders
Physical & TB Skin Test
How many patients are you paying for?
(Required)
1
2
3
4
5
6
7
8
Was any additional testing required?
No
Yes
Cost of Additional Testing
(Required)
Chest X-ray Orders (Positive Skin Test)
Repeat Skin Test
TB Skin Test
Name of patients you are paying for [Click the + sign to add more names]
(Required)
Employee First Name
Employee Last Name
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Total
Credit Card / Debit Card Info
Card Details
Cardholder First and Last Name
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