Gold Program - MiracleBarbieMD

Step 1 Complete and submit form below.

Step 2 A Team Member will contact you within 24 hours to get you started.

Step 3 Any questions or concerns, contact 1-877-993-2838
Do you have a bank account? *

Personal Business Both
Do you want to receive payments as: *

You (Personal) Business
Are you currently servicing veterans? *

Yes No
Would you like to accept Medicaid? *

Yes No
Would you like to become a registered provider? *

Yes No
Are you licensed? *

Yes No
Are you interested in attracting Non Surgical Hair Replacement Clients? *

Yes No
Name *

First Name Last Name
Business Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Note: I understand that I am paying $333 down and I will be charged $333 every 2 weeks to pay the balance.
My Products
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Gold Programs ( $ 333.00 for the first payment then, $ 333.00 for each two weeks )
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