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Immunizations/Reproductive Health Payment

Patient Number: *
Located at the top left side of the statement underneath the logo
Patient Name: *
Located on the line below the patient number
Patient Date of Birth: *
Please enter as MM/DD/YY
Daytime Phone Number: *
Please include area code and format like (xxx)xxx-xxxx
Payment Amount: *
Note/Comment (Optional):
40-character limit

Additional Information

For billing inquiries, to make payment arrangements, or to update your insurance or address information please call 208-327-8510.

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