Patient Name *

First

Last

Account Number *

5 digit account number can be found on your statement

Email

Email

Confirm Email

Receipt will be sent to email address provided, no other receipt will be mailed. If you do not have access to email to receive a receipt, in the Additional Information box below type, 'Please mail my receipt'.

Address *

Address Line 1

Address Line 2

City

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Zip Code

Amount to Pay

Stripe Credit Card *

Card

Name on Card

Additional Information (Address Changes, Receipt requests, etc)

Credit Card Refund Notice *

• Processing fees will not be refunded for any reason. Please verify the amount you are paying is due to Life Touch EMS based in Salina, KS and the amount you are paying is accurate. Other payment options are available. By clicking this box and submitting payment, you understand that once you submit payment, any credit card/debit card fees incurred in association with this transaction are non refundable and will be deducted from any refunds.

One Time Payment Authorization

By clicking submit, I authorize Life Touch EMS to charge my credit/debit card for the amount listed above. I understand that once I submit payment, any credit card/debit card fees incurred in association with this transaction are non refundable and will be deducted from any refunds.

Email

Submit