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MS SF PLNS TO PKS EMS TRA
2222 North Nevada Ave
Colorado Springs,CO 80907
(719) 776-5920

STEP 1
Payment
       
STEP 2
Confirm
       
STEP 3
Receipt


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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
Event Description
Last Name
First Name  Middle :
  (MM/DD/YYYY)
Phone #  -  - 
Email Address
Address
Address
City
State        Zip    -
Zip    -
Country

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  
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Account Information

Address 1
Address 2
City
State        Zip    -
Zip    -
Country
 -  - 
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until all information is confirmed in the next step.
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