Bill Pay – Lakewood Family Clinic

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Prefix First Middle Last
Last 4 SN#*
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Date of Birth*
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Total Due Now
$0.00
I {Name (Prefix):1.2} {Name (First):1.3} {Name (Last):1.6} authorize Lakewood Family Clinic to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services I chose above, for the total amount {Total Due Today:15} only, and is valid for one-time use only. I certify that I {Name (Prefix):1.2} {Name (First):1.3} {Name (Last):1.6} is an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Your IP Address is: 188.143.244.145
You are using: Mozilla/5.0 X11; Ubuntu; Linux x86_64; rv:126.0 Gecko/20100101 Firefox/126.0
Refered from: https://lakewoodfamilyclinic.com/bill-pay/
Todays Date: 12/05/2025
Payment Authorization
I {Name (Prefix):1.2} {Name (First):1.3} {Name (Last):1.6} authorize Lakewood Family Clinic to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services I chose above, for the total amount {Total Due Today:15} only, and is valid for one-time use only. I certify that I {Name (Prefix):1.2} {Name (First):1.3} {Name (Last):1.6} is an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. My IP Address is: 188.143.244.145 I am using: Mozilla/5.0 X11; Ubuntu; Linux x86_64; rv:126.0 Gecko/20100101 Firefox/126.0 I filled out this form using the page: https://lakewoodfamilyclinic.com/bill-pay/ Today's date is: 12/05/2025

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301.925.7022