Print out this form using your browser, then fill in the information needed to place your order. Fax the completed form to us at (817)977-1240. We will process it right away and send your order to you within 24 hours (excluding weekends).

ORDERING INFORMATION:

Quantity
ACES + ZINC, 60 softgels, $12.95 USD each.
SCAR SO SOFT, 1 ounce (30 ml) bottle, $19.95 USD each.
SEACURE, 180 capsules, $23.95 USD each.

CUSTOMER INFORMATION:

NOTE: All fields marked with an * are REQUIRED!

First Name:* ______________________________________________________________

Last Name:* ______________________________________________________________

e-mail address* ____________________________________________________________

Address Line1* ____________________________________________________________

Address Line2 _____________________________________________________________

City* ____________________________________________________________________

Province/Territory* _________________________________________________________

Postal Code* _____________________________________________________________

CANADA

Work or Home Phone Number _______________________________________________


SHIPPING INFORMATION:

What type of shipping do you want (Please fill in) ?

_______________________________________________________________________

Shipping & Handling Costs are as follows:

U.S. Express Mail - usually 4 to 5 day delivery time, $24.00 USD for up to 8 ounces (0.23 kg, 1-2 bottles), $28.00 USD for 1 pound (0.45 kg, 3 to 5 bottles).
U.S. Air Mail - usually 7 to 10 day delivery time, $6.00 USD for up to 1 pound (0.45 kg, 1-5 bottles).

PAYMENT INFORMATION:

Credit Card Type: (fill in one circle)
Visa MasterCard American Express Discover

Credit Card Number: ______________________________________________________

Expiration Date (Month/Year): ______________________________________________

Name of the person as it appears on the credit card (REQUIRED):

_________________________________________________________________________

Comments/Suggestions:

USE THE PRINT OPTION ON YOUR BROWSER TO PRINT A COPY OF THIS FORM. FILL IT IN AND FAX THE COMPLETED FORM TO US AT (817)977-1240.

Return to ABOUT SCARS & KELOIDS order page in English for Canada.