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, US $12.95 each.
SCAR SO SOFT, 1 ounce (30 ml) bottle, US $19.95 each.
SEACURE, 180 capsules, US $23.95 each.

CUSTOMER INFORMATION:

NOTE: All fields marked with an * are REQUIRED!

First Name:* ______________________________________________________________

Last Name:* ______________________________________________________________

e-mail address*____________________________________________________________

Address Line1*____________________________________________________________

Address Line2 _____________________________________________________________

City*____________________________________________________________________

State or Province (If Applicable) _______________________________________________

Postal Code/ Number (If Applicable) ___________________________________________

Country* _______________________________________________________________

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 5 to 7 day delivery time, US $28.00 for up to 8 ounces (0.23 kg, 1-2 bottles of SCAR SO SOFT), US $33.00 for up to 16 ounces (0.45 kg, 3-5 bottles of SCAR SO SOFT).
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U.S. Air Mail - usually 14 to 21 day delivery time, US $9.00 for up to 16 ounces (0.45 kg, 1-5 bottles of SCAR SO SOFT).
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We do NOT ship packages via US AIR MAIL to the following countries: Bulgaria, India, Indonesia, Poland, Romania, Seychelles, Slovenia or Yemen.
We do NOT ship packages to the following countries: Afghanistan, Angola, Bangladesh, Burma, Burundi, Congo, Cuba, Ethiopia, Iran, Iraq, Rwanda, Sudan or Syria.


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 International Customers.