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Secure Payment

Client First Name

Client Last Name *

Client Email *

Client Date of Birth *

Card Type *

Name of Card Holder: *

Card Number *

Exp. Month *

Exp. Year *

CVV *

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Payment Details

One Time Payment

Payment Plan

Please Charge My Credit Card *

On The Following Date: *

Set Up a Payment Plan *

Charged On This Day of the Month *

Over This Many Months *

Other Payment Options

UPDATE my payment plan with the above new credit card information

Further Instructions:

QUESTIONS?

Mondays to Fridays
8:30 am-5:00 pm EST

Former Address:
45 St. Clair Ave. W, Suite 901
Toronto, ON M4V 1K9

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