Line D - Facial Treatment Order form

Name: _______________________________________________________________________

Address: _____________________________________________________________________

City:_________________________State: ____________________Zip Code: _______________

Phone #1: ______________________________Phone #2: ________________________________

ShipTo:(if different from above)_____________________________________________________

Credit Card Number: _______________________________Expiration Date: _____/_____/_____

Signature: ________________________________________ Visa; MC; AMEX; Disc; (Circle one)

Print this order form. Fill it in, fax it to (415) 398-5016 or mail it to the address above or call us now @ (800) 568-4247 ______ International Customer please call (415) 398-2580


Shipping charge are calculated based on weight of purchase and ship to location. Sales tax of 8.25% applies in California.