Bill Pay – Lakewood Family Clinic

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Prefix First Middle Last
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Date of Birth*
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Street Address Address Line 2 City State ZIP Code

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: 20.223.93.176
You are using: Mozilla/5.0 (Windows NT 10.0; WOW64; Trident/7.0; rv:11.0) like Gecko
Refered from:
Todays Date: 04/18/2025
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: 20.223.93.176 I am using: Mozilla/5.0 (Windows NT 10.0; WOW64; Trident/7.0; rv:11.0) like Gecko I filled out this form using the page: Today's date is: 04/18/2025

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301.925.7022