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I hereby authorize MagneFUSE, LLC to charge the credit card listed above for the payment of all prescription orders. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. Applicants may revoke this credit card on file by submitting a written request to the address at the top of this form. A new form must be submitted if any information such as credit card expirations or authorized users is changed. Applicants agree to pay the cost for any returned or challenged payments. *

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