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Your Name First Name Last Name Your Address Street Address City State / Province Postal / Zip Code CASH CHECK DISCOVER VISA MASTERCARD On extensive treatments over 5 000 I would like to pay in full ahead of time in order to take advantage AMEX of a 5 bookkeeping courtesy. I will use the following payment method s on all visits at treatment progresses YES NO Insurance Company Name I will pay the deductible amount listed here and any out of pocket portion at the time of treatment.
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