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Special Pay From the Heart Checkout Form:

Last Name

Billing Address

Billing Address 2

Billing City

Billing Country

Billing Zipcode

Cell Number

Alternate Phone Number

Please choose the amount that you feel you can afford to pay below:

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

Submit