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NOTE:Please Enter The Amount You Have Been Asked To Pay By Health Records Board

Service:

Payment Ref:

Payer Surname:

Payer Surname is Required.

Payer Firstname:

Payer Firstname is Required.

Payer Othername:

Payer Email:

Email is Required. Invalid Email

Payer Phone:

Phone Number is Required.

Amount To Pay:

Payment Amount is Required. You can only enter numeric values for Pay Amount

Index/License Number:

Index/License Number is Required.