Checkout - AAOPM

Customer Information

First Name *

Last Name *

Medical Title

Email Address *

Phone Number *

Are you a Practice Owner?

State License #

Account Rep (if any)

Billing Address

Address *

Address Line 2

City *

State *

Zip Code *

Country

Payment Method

eCheck / ACH

No Processing Fee

Credit Card

3% Fee ($1,549.44)

Account Type *

Bank Name *

Routing Number *

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 *

Order Summary

AAOPM Custom - 2 Workshops

− 4 + × $3,058.00

Remove

$12,232.00 $3,398.00

AAOPM Custom - 4 Workshops

− 4 + × $4,757.00

Remove

$19,028.00 $6,796.00

AAOPM Custom - 5 Workshops

− 4 + × $5,097.00

Remove

$20,388.00 $8,495.00

Subtotal $51,648.00

Total $51,648.00

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