Print out this form using your browser, then fill in the information needed to place your order. Mail the completed form to us at the following address:

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 OR with your personal check.

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):

_________________________________________________________________________

PERSONAL CHECK PAYMENTS

Check this box if you are paying by personal check. Include your check with this form. Please make your check payable to NATURE DOC. Do not forget to include the cost of shipping. Any check returned for NSF will be assessed a $30.00 fee.

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