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Description	Payment for Initial Visit at Bright Futures Chiropractic
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Card Verification Code*	what's this?

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I authorize Bright Futures Chiropractic to debit the account listed hereon $97.00, & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct.

Bright Futures Chiropractic
P.O. Box 712, 131 E Avenue Kalona, IA 52247
(319) 656-2888

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