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Your Order
Order Options
Place your order by phone (877-730-2727)
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Complete this form, print, and Fax (618-236-2826)
Complete this form, print, and mail to:
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Ordered by:
Name: Street Address: City: State: Zip: Phone: Email: Fax: Contact Name & Title
Ship to: (if different)
Name: Street Address: City: State: Zip: Phone: Email: Fax: Attention:
Personal 4 fl oz, up to 2 treatments
$
Personal Size Kit Includes nit comb & two shower caps
Family Size 16 oz, up to 8 treatments
Shipping & Handling
Michigan Sales Tax (6%, if applicable)
Visa MasterCard Card Number: Expiration Date: 00/00 / Name Appearing on Card:
Belleville, Illinois