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 Online Purchase Form 

Please complete the form below with the address in the credit card statement. May buy up to 2 deal for each package per customer.


First Name:
Last Name:
Address 1:
Apt./Ste #:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Credit Card Type:
Credit Card #:
Exp. Date Month:
Exp. Date Year:
CVV: Visa:3 Digits / Amex:4 Digits
Package #1:
Package #2:
Amount: (Format: 000.00)
Comments:


     Package # 1

Facelift Laser Skin Tightening
•Cleanser
•Exfoliation
•Peeling Oxigenate
•RF Laser Skin   Tightening
•Facial Massage with Hyaluronic Acid & Mask
Price: $99.00

      Package # 2

Sun Spot/Antiaging Treatment 
•Cleanser
•Exfoliation
•Microdermabrasion
•IPL Photorejuvenation
•Cool Collagen Mask
Price: $99.00
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