Carbon County Ambulance
             
Carbon County Ambulance Services
 
Account Information
Patient's Name
 
Payment Amount:   $   Item Subtotal:  
$0.00
Total:
$0.00

Personal Information:
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:

Please be aware that card payments will be described as
CBT*Carbon County UT

Account Information is required
Patient's Name is required
First Name: is required
Last Name: is required
Address: is required
City: is required
State/Province: is required
ZIP/Postal Code: is required