Uinta County Public Health
             
Uinta County Public Health
 
Receipt Number

General Fund:   $   Item Subtotal:  
$0.00
Catagories
[1] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[2] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[3] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[4] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[5] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[6] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[7] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[8] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[9] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee


Catagories

[10] WYVip Immunizations
ST
TST
STD Donations
Other Clinic Fees
Lab Test/Consult Fee

Private IMM:   $   Item Subtotal:  
$0.00
Catagories
[1] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[2] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[3] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[4] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[5] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[6] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[7] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[8] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[9] Adult/Child Flu
Private Immunications
Consultations Fee


Catagories

[10] Adult/Child Flu
Private Immunications
Consultations Fee

Womens Health:   $   Item Subtotal:  
$0.00
Categories
[1] BP-Rental
EC
Pregnancy Test


Categories

[2] BP-Rental
EC
Pregnancy Test


Categories

[3] BP-Rental
EC
Pregnancy Test


Categories

[4] BP-Rental
EC
Pregnancy Test


Categories

[5] BP-Rental
EC
Pregnancy Test


Categories

[6] BP-Rental
EC
Pregnancy Test


Categories

[7] BP-Rental
EC
Pregnancy Test


Categories

[8] BP-Rental
EC
Pregnancy Test


Categories

[9] BP-Rental
EC
Pregnancy Test


Categories

[10] BP-Rental
EC
Pregnancy Test

Wellness:   $   Item Subtotal:  
$0.00
Categories
[1] Blood Sugar
Diabetes Education
Wellness


Categories

[2] Blood Sugar
Diabetes Education
Wellness


Categories

[3] Blood Sugar
Diabetes Education
Wellness


Categories

[4] Blood Sugar
Diabetes Education
Wellness


Categories

[5] Blood Sugar
Diabetes Education
Wellness


Categories

[6] Blood Sugar
Diabetes Education
Wellness


Categories

[7] Blood Sugar
Diabetes Education
Wellness


Categories

[8] Blood Sugar
Diabetes Education
Wellness


Categories

[9] Blood Sugar
Diabetes Education
Wellness


Categories

[10] 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:
Health Services 800-764-0844

Payment Information
Method of Payment:
Processing Fees: Credit cards: 2.5% ($2.50 min)
                    (+1.5% processing fee for foreign cards)
eChecks: $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:
Credit Card Number: (Type number or swipe with cursor in this empty field)
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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