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I authorize Back to Health Chiropractic to debit the account listed hereon $27.00, & 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 Back to Health Chiropractic Terms as referenced in the [Terms of Use] link below.

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Back to Health Chiropractic
2504 Monroe Street La Porte, IN 46350
(219) 326-5100

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