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* ____________________________________________________________________

Country* ________________________________________________________________

Zip Code* _______________________________________________________________

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. First Class Mail - $6.00 for up to 13 ounces.
U.S. Priority Mail - $7.00 for up to 1 lb.
U.S. Express Mail - $26.00 for up to 8 ounces, $33.00 for up to 1 lb.

PAYMENT INFORMATION:

You can pay for your order with your credit card.

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):

________________________________________________________________________

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 Territories/Associations.