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Oneida Center For Rehab
1445 Kemble Street • Utica, NY 13501
Personal Information
Full Name
*
Address
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Phone Number
Email Address
*
Transaction Details
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*
+ Convenience fee: 3%
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By clicking this form, you give Oneida Center For Rehab permission to charge your account as indicated below. This does not provide authorization for any additional unrelated charges to your account.
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Oneida Center For Rehab
1445 Kemble Street
Utica, NY 13501
Tell: 315-732-0100
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
