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Follow Up Medical Care and Hospitalization
Case Number:
Patient's Information:
Last Name:
First Name:
Middle Initial :
Your Name (As Payor):
Last Name:
First Name:
Middle Initial :
Country Code: City Code: Mobile Number:
Mobile Number:
Payment Information:
Case Number (from Company eMail)
Payment Due(from Company eMail)
I agree to the
Terms and Conditions
of this service.
I do not agree to the Terms and Conditions of this service.
Within 24 hours of receipt of payment, we will confirm the appointment with you, and we will contact your patient-relative directly to confirm the same.
Patient should proceed to the designated office in the specified hospital where our Service representative will bring them to their appointment.
Pay the Amount Due via Pay Pal plus any remittance fee that Pay Pal may charge for its service.
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