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Customer Information

First Name *

Last Name *

Medical Title

Email Address *

Phone Number *

Are you a Practice Owner?

State License #

Account Rep (if any)

Address *

Address Line 2

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State *

Zip Code *

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eCheck / ACH

No Processing Fee

Credit Card

3% Fee ($8,515.74)

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Bank Name *

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Account Number *

Name on Account *

By providing your bank account information, you authorize AAOPM to debit your account for the amount shown.

eSignature (Type your full name) *

Card Type *

Card Number *

Expiration Month *

Expiration Year *

CVV *

AAOPM Livestream Membership

− 142 + × $1,999.00

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$283,858.00

Subtotal $283,858.00

Total $283,858.00

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