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Clinic Information

Clinic Email
Clinic Phone Number
Shipping Address

Billing Address (optional)

Credit Card Information (Visa, Mastercard, Amex) (optional)

Invoices are charged after the delivery
I, the applicant, agree that the information provided above is factual and, upon credit approval, will adhere to the TERMS set forth by the company. Any accounts over 45 days will have all orders held. A 3% monthly fee charge applies to all past due accounts.
Clinic Website (optional)