Please fill out form below to pay for eye glasses for a patient at Maricopa County Correctional Health Services.
Please fill out below as the person paying for patient.
Please fill out patient information below.
Once you submit the form, you will be sent an email with a transaction ID. You will be required to provide this ID when submitting payment. An eye exam will be scheduled once payment is received.
For safety concerns the patient will not be notified in advance of the appointment date/time.
This field is not part of the form submission.
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