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$3,058.00
Discount already applied!

Registration: $3,058.00
Credit Card Convenience Fee: $91.74
Total Amount Due: $3,149.74

1 - Customer Information

First Name:

Last Name:

Medical Title:

Email Address:

Telephone:

Are you a Practice Owner?:

State License #:

Name of Account Rep who guided you, if any:

2 - Payment Information

eCheck Payment

Account Type:

Bank (Institution) Name:

Routing Number:

Account Number:

Name on Account:

Amount to be Charged:

Date:

Email for Confirmation:

I (we) understand that this authorization will remain in full force and effect until I (we) notify AAOPM, INC. in writing at the following:

AAOPM, Inc.
2720 East Oakland Park Blvd, #102
Fort Lauderdale, FL 33306
(954) 525-4273
(954) 358-2860 (F)

That I (we) wish to revoke this authorization.

Name(s):

Date:

eSignature: (Please type your full name)

Credit Card Payment
(3% Convenience fee ($91.74))

Card Type:

Credit Card Number:

Expiration Date:

CVV:

3 - Billing Information

Address:

Address 2:

I acknowledge that I have read and agree with the AAOPM terms of service, privacy policy, and cookie policy. California courses attendees: In order to inject during hands-on sessions, you need to be licensed to inject in California.

Amount to be charged: $3,149.74


AAOPM Custom - 2 Workshops	$3,058.00 Discount already applied!
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empty cart Registration: $3,058.00 Credit Card Convenience Fee: $91.74 Total Amount Due: $3,149.74

Your Registration

1 - Customer Information

2 - Payment Information

eCheck Payment

Credit Card Payment(3% Convenience fee ($91.74))

3 - Billing Information

Credit Card Payment
(3% Convenience fee ($91.74))