Oro Selket
Tel 310-710-4888 fax call first
Date:
Name, First                                Last                                        (name as on credit card)
Address:                                                                                    (credit card billing address)
City                                                                              State         Zip
Telephone (____) _____-_______      Fax (____) _____-_______
Credit card number                                                           Credit card type
Expiration date  Month:                                Year:
Amount: $50.00 - Fifty US Dollar -
Complimentary Healthcare Disclosure:
Oro Selket is not licensed by the state as a healing arts practitioner,
but is qualified in their field of expertise. I have read and understand
this Complimentary Healthcare Disclosure.
Signature:

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