Ambulance USA, LLC

Secure Payment Form

Trip Reference Number
Date of Transport
Patient's First Name
Patient's Last Name
Service Type Requested
Order Amount in USD
Convenience Fee (4%)
Total Amount
Name as on Card
Card Number
Card Expiration Date
Card Billing Address
Card Billing Zip
Do you want Ambulance USA, LLC, to securely store your payment and contact information for future recurring cases or transports?
Company Name
First Name
Last Name
Phone Number
Email Address
Your Initials

I accept and agree with the General Terms and Conditions of Ambulance USA, LLC. and with the processing of my personal data in accordance with the Privacy Statement of Ambulance USA, LLC. Please note that a 4% convenience fee is added to every transaction.