Weeks Medical Center On Line Inquiry

Please write your invoice number on your check.
Make check payable to Weeks Medical Center.

Patient Name:

Card Number:

3 Digit Code:

Signature:

Exp Date:

Statement Date

Invoice Number

Patient Name

Amount Paid
$______.___

AMOUNT DUE
$

Service Date

Make check payable and send to:

WEEKS MEDICAL CENTER
PO BOX 240
WHITEFIELD, NH 03598-0240

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PATIENT NAME
INVOICE NUMBER
SERVICE DATE(S)
TOTAL CHARGES	$
INS PAYMENTS/ADJ
PATIENT PAYMENTS
DISCOUNTS/OTHER TRANSACTIONS

YOUR RESPONSIBILITY TO PAY
$

Thank you for choosing Weeks Medical Center for your healthcare needs.