Patient Information

First Name*

Last Name*

Phone Number*

Email Address*

Billing Information

First Name*

Last Name*

Address*

Order Information

Account # or Claim #*

Payment*

By checking this box,

You acknowledge and agree that Irondequoit Ambulance charges a convenience fee of 3% for each credit card transaction processed. These fee's are non-refundable and will be automatically added to your charge.

To avoid convenience charges, you may send a payment via check or money order to Irondequoit Ambulance P.O. Box 16996, Rochester, NY 14616.

I agree with the terms & conditions above

Pay Bill Online

Patient Information

Billing Information

Order Information