Print out this form using your browser, then fill in the information needed to place your order. Fax the completed form to us at (808)356-0166. 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 $29.95 each.

CUSTOMER INFORMATION:

NOTE: All fields marked with an * are REQUIRED!

First Name:* ______________________________________________________________

Last Name:* ______________________________________________________________

e-mail address* ____________________________________________________________

Address Line1* ____________________________________________________________

Address Line2 _____________________________________________________________

City* ____________________________________________________________________

State* ___________________________________________________________________

Postal Number* ___________________________________________________________

MEXICO


SHIPPING INFORMATION:

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

_______________________________________________________________________

Shipping & Handling Costs are as follows:

U.S. Express Mail - US $18.00 for up to 1 lb.(2.2 kg), usually 3 to 4 day delivery time. Insured for loss.
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U.S. Air Mail - US $5.00 for up to 1 lb.(2.2 kg), usually 10 to 14 day delivery time. You except all risk for loss!
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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 (808)356-0166.

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