Step 1: Select Payments
Step 2: Review and Submit
Step 3: Confirmation and Receipt
Step 1: Select Payments

Please complete the FireMed Registration and Payment information below. When finished, click the Continue button and you will be asked to review the information for accuracy before you process.

All memberships are valid through October 31, 2018 and apply to residents served by the City of Dallas Ambulance Service.

If you have questions, please call 800-238-9398

City of Dallas Residents pay $65 a year for the entire household
Non-Residents (including Rickreall and Falls City) pay $75 a year for the entire household.

Please provide your name (first, middle initial, last) and date of birth, along with the name and dates of birth, of all household members to be covered under this membership.

Note: * indicates a required field.

My Bills
Payment Type: *

Primary Member
First Name: *
Middle Initial: *
Last Name: *
Date of Birth: *
Home Address: *
City: *
State: *
Zip: *
Phone Number: *
Email Address: *

Mailing address different than your home address?
Mailing Address:
City:
State:
Zip:

Other Household Members
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
FirstName:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
LastName:
Date of Birth:

Cardholder Information
First Name: *
Last Name: *
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Phone Number: *
Email Address: *

Payment Information
Payment Method: *
Card Number: * 
Expiration Date: * (in mm/yy format)