Nxt Lvl Chiropractic Wellness Membership Program

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Congratulations! You have chosen wisely! Please fill out the requested information to begin your membership!

Membership Option *

Solo ($69/month)

Duo ($99/month)

Fam ($149/month)

Solo Jr ($30/month) (Under 18 years)

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Card Number *

Expiration *

Card Verification Code *

Recurring Payment Authorization Form *

I hereby authorize Nxt Lvl Chiropractic to bill the credit/debit/HSA/FSA card listed hereon for the individual / family option that I choose above beginning today and agree to perform the obligations set forth by the credit/debit card issuer and the terms of the membership agreement. I will not dispute the company’s recurring billing with my bank or credit card company; so long as the transaction corresponds to the terms indicated in this agreement

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Name *

Billing address *

Phone *

E-mail *

Signature *

Typing your name here indicates the equivalent as a signature

Date *

YYYY

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