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 each.
SCAR SO SOFT, 1 ounce (30 ml) bottle, $19.95 each.
SEACURE, 180 capsules, $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* ___________________________________________________________________

Zip Code* _______________________________________________________________

USA

The address above is a (fill in one circle):
Business Address Residential Address

Work Phone Number _______________________________________________________

Home Phone Number _______________________________________________________

Fax Phone Number _________________________________________________________


SHIPPING INFORMATION:

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

_______________________________________________________________________

Shipping & Handling Costs are as follows:

UPS Ground - $8.00 There is an additional charge of $2.00 for delivery to remote areas.
UPS Second Day Air - $20.00 (Delivery in 2 business days, does not include weekends.)
NOTE: There is an additional charge of $2.00 for UPS deliveries to remote areas!
U.S. First Class Mail - $6.00 for up to 13 oz. (Delivery in 4 to 7 days.)
U.S. Priority Mail - $7.00 for up to 1 1b. (Delivery in 2 to 3 days.)
U.S. Express Mail (delivery in 1 to 2 days, will deliver on the weekends.) - $19.00 for up to 8 oz. (1-2 bottles of Scar So Soft), $23.00 for up to 1 lb. (3-5 bottles of Scar So Soft).

PAYMENT INFORMATION:

CREDIT CARD PAYMENTS

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 US Customers.