<form action="https://hosted.transactionexpress.com/Transaction/Transaction/Index" method ="POST" target="_blank" >
<input type="hidden" name="HostedKey" id="HostedKey" value="13575a30-b405-49e0-a4d6-8da8fefedf1f" />
<input type="hidden" name="Gateway_ID" id="Gateway_ID" value="9210498625" />
<input type="hidden" name="IndustryCode" id="IndustryCode" value="2" />
<input type="hidden" name="Amount" id="Amount" value="" />
<input type="hidden" name="PaymentType" id="PaymentType" value="CC" />
<input type="hidden" name="RecurringType" id="RecurringType" value="N" />
<input type="hidden" name="RecurringAmount" id="RecurringAmount" value="" />
<input type="hidden" name="RURL" id="RURL" value="" />
<input type="hidden" name="CURL" id="CURL" value="https://www.southpointepeds.net/pay-online/" />
<input type="hidden" name="AVSRequired" id="AVSRequired" value="Y"/>
<input type="hidden" name="CVV2Required" id="CVV2Required"value="Y"/>
<input type="hidden" name="EmailRequired" id="EmailRequired" value="Y"/>
<input type="hidden" name="PostRspMsg" id="PostRspMsg" value="N"/>
<p>*Patients First & Last Names: <input required name="custrefid" type="text" size="50" maxlength="50" /></p>
<input type="Submit" name="Submit" id="Submit" value="Pay Now" />
</form>

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