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PLC:

a0062c

Agency:

van buren cass district health department

For:

clinical health

Phone:

269-621-3143

Address:

260 south street
lawrence, michigan 49064

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*Patient Name:

Middle:

*Last:

*Patient Date of Birth:

(Month / Day / Year)

*Service Type:

*Location:

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*Payment Type:

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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