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Legacy Lab Online Pmt
Legacy Laboratory Services
PO Box 5337
Portland,OR 97228-5337
(503) 413-4420

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt
Payment Type

           
Credit Card Bank Account

Patient
*Bold fields are required



Patient ID PatientMedicalRecordNumber First Name Last Name Birth Date PatientServiceBeginDate PatientServiceEndDate AdditionalInfo1 Additional Info 2 Additional Info 3 Additional Info 4 Additional Info 5 Additional Info 6 Amount
Add Row Total $0.00
Statement #
Patient Last Name
Patient First Name  Middle :
Patient Birth Date   (MM/DD/YYYY)
 -  - 
FIN / Account #
Service Date
       Zip    -
Note/Memo

Payment Information

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Card :
Card Holder Name
Card Type
Card Number   Exp Date   (MM/YY)
CVN   What is this?
Amount            Current Balance  
Save this card for future use

Account Information

       Cardholder Zip    -
Cardholder Zip    -
Cardholder Phone # (For Legacy Customer Service use only)  -  - 
  Your credit card/bank account will not be charged
until all information is confirmed in the next step.
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