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Uinta County Public Health
Receipt Number
General Fund:
$
Item Subtotal:
$0.00
Catagories
WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee
Private IMM:
$
Item Subtotal:
$0.00
Catagories
Adult/Child Flu
Private Immunications
Consultations Fee
Womens Health:
$
Item Subtotal:
$0.00
Categories
BP-Rental
EC
Pregnancy Test
Wellness:
$
Item Subtotal:
$0.00
Categories
Blood Sugar
Diabetes Education
Wellness
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:
CBT*Uinta Public Hlth
Payment Information:
Processing Fee Rates:
Cards:
2.5% ($2.50 min)
(1.5% surcharge for foreign cards)
eCheck:
$0.75
Method of Payment:
Credit/Debit Card
eCheck
Update Name from Above
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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