Bill Pay – Lakewood Family Clinic

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Prefix First Middle Last
Last 4 SN#*
Email*
Date of Birth*
Phone*
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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: 34.77.84.180
You are using: Mozilla/5.0 (compatible; VelenPublicWebCrawler/1.0; +https://velen.io)
Refered from: https://www.lakewoodfamilyclinic.com/bill-pay
Todays Date: 09/09/2024
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: 34.77.84.180 I am using: Mozilla/5.0 (compatible; VelenPublicWebCrawler/1.0; +https://velen.io) I filled out this form using the page: https://www.lakewoodfamilyclinic.com/bill-pay Today's date is: 09/09/2024

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301.925.7022