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
Processing Fee Rates:
Cards: 2.5% ($2.50 min)
(4% for foreign cards)
eCheck (ACH): $0.75
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
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