Wellness Package Plan

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Please fill out the form below to sign up for the Wellness Package Plan. I will contact you to schedule an introductory meeting and send you sign up forms before Sign up is complete. Sign-up is complete when we have spoken together and signed the necessary forms. I will process your payment on the date choosen in accordance with our agreement. 

Name *
Name
Address *
Address
$125 monthly starting on the 1st of next month, $100 for the first month if paid at sign up.
$
Phone *
Phone
Card number
Expiration Date *
Expiration Date