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

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. Priority Mail - $7.00 for up to 1 lb.
U.S. Express Mail - $18.80 for up to 1 lb.

PAYMENT INFORMATION:

You can pay for your order with your credit card OR from your checking account.

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):

________________________________________________________________________

CHECKING ACCOUNT PAYMENTS

You can pay for your order with funds from your checking account. Just enter the information "EXACTLY" as it appears on your check into the boxes below. We will "cut a check" using the information you provide and send you a copy of it with your order.

Saves time! Saves money (no stamp)! No need to write and mail us your check.

If you have trouble locating the information that is needed for the form below, please take a look at the sample check below this form for some additional help.

PLEASE NOTE: All checks returned due to Non-Sufficient Funds (NSF) will be charged a $25.00 NSF Fee! Also, please void the check that you use so that you do not use the same check number twice!

Your name Your address City Country Zip code	Check # ABA # The ABA # is located close to your check # and looks like this 01-5678/1234
Pay To The Order Of   NATURE DOC Your Bank's Name Your Bank's Address (May omit if not on check.) Your Bank's City Your Bank's Country Your Bank's Zip Code Enter the numbers from the bottom of your check in the 2 boxes below:     Routing #                                       Account #

The sample check below provides some additional help for locating the information needed in the above form.

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)626-0248.

Return to ABOUT SCARS & KELOIDS order page in English for US Territories/Associations.