Purpose Driven Chiropractic

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Description	2019 VIP Pass
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I authorize Purpose Driven Chiropractic to debit the account listed hereon $77.00, & 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 Purpose Driven Chiropractic Terms as referenced in the [Terms of Use] link below.

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Purpose Driven Chiropractic
1155 E Winding Creek Dr Eagle, ID 83616
(208) 938-9548

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