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Helixor Secure Credit Card Form
This is a secure form. Please note only credit cards associated with the clinic or practitioner placing the order can be used.
Name
*
Account Number (4 digits, on your invoice) - if for brand new account only, write "NEW"
*
Clinic Phone Number
*
Credit Card Type
*
Visa
MasterCard
American Express
Name on Card
*
Credit Card Number (no spaces)
*
Expiration Date (mm/yy)
*
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