Bill Pay – Lakewood Family Clinic

Name*
Prefix First Middle Last
Last 4 SN#*
Email*
Date of Birth*
Phone*
Address*
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: 104.196.36.144
You are using: ZoominfoBot (zoominfobot at zoominfo dot com)
Refered from:
Todays Date: 01/13/2025
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: 104.196.36.144 I am using: ZoominfoBot (zoominfobot at zoominfo dot com) I filled out this form using the page: Today's date is: 01/13/2025

Step 1 of 3 - Services

SCHEDULE A VISIT

Step 1 of 3 - Services

301.925.7022