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WOHC Patient Account Payment
 
* Account Number:
Refer to your statement
* Payment Date:
* Payment Date: / /
* Patient Name:
Last Name,First Name (e.g. Smith,John).
Patient Address:
Include province/state, and postal code
Patient Home Phone:
Include area code. Do not enter hyphens or spaces (e.g. 4161234567).
Patient Work Phone:
Include area code. Do not enter hyphens or spaces (e.g. 4161234567).
Admission Date:
mm/dd/yyyy
* Amount of Payment:
Enter the total amount payable as shown at the bottom of your bill.
* Mandatory Field
 
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