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

Patient Payment Portal

USD Amount to be paid

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

Should be Empty: