Bill Pay – Lakewood Family Clinic

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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: 184.154.76.56
You are using: Mozilla/5.0 (compatible; MSIE 9.0; Windows NT 6.1; WOW64; Trident/6.0)
Refered from: http://www.google.com/url?url=www.lakewoodfamilyclinic.com&yahoo.com
Todays Date: 12/14/2024
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: 184.154.76.56 I am using: Mozilla/5.0 (compatible; MSIE 9.0; Windows NT 6.1; WOW64; Trident/6.0) I filled out this form using the page: http://www.google.com/url?url=www.lakewoodfamilyclinic.com&yahoo.com Today's date is: 12/14/2024

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301.925.7022