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Please select the payment option for the price that best fits your needs below:

First Name

Last Name

Billing Address

Billing Address 2

Billing City

Billing Country

Billing Zipcode

Cell Number

If you have questions about this registration form or need assistance with one of the payment options, please contact our enrollment department: courses@drjaffemd.com or call 1-888-527-7233 ext. 1.

Name On Card

Card Number

CVC

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