Dr. J Salomon

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PAYMENTS
FORMS
Spanish Version
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Payments

PROCEDURES:
FACE
BODY
BREAST
MED SPA:
CoolsculptingLNav2
Amount: Patient’s Name: Email: Street: City: State: Zip:
Card Type: Card Number: ` Expiration: Name On Card: Cvv:
I am requesting and give consent for my credit card to be charged for the amount referenced above.