Colorado Health and Wellness Center

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I authorize Colorado Health and Wellness Center to debit the account listed hereon $300.00, & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct.

Colorado Health and Wellness Center
3333 S Wadsworth Blvd, Ste. D-228 Lakewood, CO 80227
(720) 570-2500

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