Online Payment Portal

SouthBridge EMS Online Payment Portal
Patient's Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail
example@example.com
Claim Number *
i.e. 17-123456
Date of Service

- Month - Day Year Date Picker Icon

Payment Amount

USD

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Enter the message as it's shown *
Should be Empty: