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I authorize HealthQuest of Fields Ertel, Inc to debit the account listed hereon $21.00, & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept HealthQuest of Fields Ertel, Inc Terms as referenced in the [Terms of Use] link below.

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HealthQuest of Fields Ertel, Inc
8390 E. Kemper Road Suite A Cincinnati, OH 45249
(513) 774-9800

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