Name: _______________________________________________________________________________

Address: _____________________________________________________________________________

City:___________________________State: ______________________Zip Code: ___________________

Phone#1: _________________________________Phone2: _____________________________________

ShipTo:(if different from above)____________________________________________________________

Credit Card Number: _________________________________________Expiration Date: ____/____/____

Signature: ______________________________________________ Visa; MC; AMEX; Disc; (Circle one)

How to place an order:

Print the above order form. You may fax it to (415) 398-5016, mail it to the address above or call us now @ (800) 568-4247______International Customer please call (415) 398-2580

Shipping charge for international orders are calculated based on location.
Sales tax of 8.5% applies in California.

The plans above are only for those who chose to become a subscription member by signing and submitting the subscription agreement on the HairPrime® Healthy Hair Program form above.