Daggett County Ambulance
             

DAGGETT COUNTY AMBULANCE

If you have any questions concerning your bill please call 435-784-3222, Ext. 410
 
Account No.
 
Ambulance Fee:   $   Item Subtotal:  
$0.00
Patient's Name [1]

Patient's Name
[2]

Patient's Name
[3]

Patient's Name
[4]

Patient's Name
[5]

Patient's Name
[6]

Patient's Name
[7]

Patient's Name
[8]

Patient's Name
[9]

Patient's Name
[10]
Total:
$0.00
Personal Information:
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:
Please be aware that your credit card statement will read
 Health Services 800-764-0844.
Payment Information
Method of Payment:
Processing Fee Rates:
Cards: 2.5% ($2.50 min)
(4% for foreign cards)
eCheck (ACH): $0.75
Update name from Personal Information
Name of Individual
on Checking Account:
Name of Individual
on Savings Account:
Name of Business
on Checking Account:
Bank Routing Number:
Bank Account Number:
Confirm Account Number:
Credit Card Number:
Expiration Date: /
Card ID (CVV2/CID) Number: What is the Card ID?
Cardholder Information (exactly as it appears on your statement)
  Update from Personal Information
Cardholder's Name:
Billing ZIP/Postal Code:
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