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Southlake Regional Health Centre Patient Account Payment
 
* Account Number:
Refer to your statement
* Invoice Date:
* Invoice Date: / /
* Patient Name:
Last Name,First Name (e.g. Smith,John)
Contact Name:
If different from Patient Name
Contact Phone Number:
Include area code e.g. 905-123-4567
* Payment Amount:
Handling fee of $2.00 is payable to online service provider, and will be added to statement amount.
* Mandatory Field
 
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