Professional Range Order Form Professional Range Order Form Shipping* PICKUP DELIVERY Clinic Name:* Phone*Postal Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PRODUCTS:Prescription / Pharmacist only items:Anaesthetic Cream/Gel | Lignocaine 2.5%, Prilocaine 2.5%, Tetracaine 4% *Pharmacist only* (30ml) Quantity Price: $ 25.00 Quantity Anaesthetic Cream/Gel | Lignocaine 2.5%, Prilocaine 2.5%, Tetracaine 4% *Pharmacist only* (50ml) Quantity Price: $ 50.00 Quantity Anaesthetic Cream/Gel | Lignocaine 23%, Tetracaine 7% (50ml) Quantity Price: $ 50.00 Quantity Anaesthetic Cream/Gel | Lignocaine 23%, Tetracaine 7% (100ml) Quantity Price: $ 80.00 Quantity Jessner Peel Weak | Salicylic acid 10%, Kojic acid 4%, Lactic acid 8% (100ml) Quantity Price: $ 75.00 Quantity Jessner Peel strong | Salicylic acid 14%, resorcinol 14%, lactic acid 14% (100ml) Quantity Price: $ 80.00 Quantity TCA peel | Trichloroacetic acid (30% - 70%) - (50ml) Quantity Price: $ 60.00 Quantity Melasma cream | Azelaic acid 10%, Kojic Acid 6%, Hydroquinone 3%, Hydrocortisone 1%, Tretinoin 0.5% (50ml) Quantity Price: $ 40.00 Quantity Professional range (NO scripts required):Mild Glycolic Peel | Glycolic acid 15% solution- buffered (pH3.5) - (100ml) Quantity Price: $ 32.00 Quantity Medium Glycolic Peel | Glycolic acid 20% solution- buffered (pH3.5) - (100ml) Quantity Price: $ 35.00 Quantity Strong Glycolic Peel | Glycolic acid 30% solution- buffered (pH3.5) - (100ml) Quantity Price: $ 40.00 Quantity Mild Lactic peel | Lctic 15% solution (100m) Quantity Price: $ 30.00 Quantity Medium Lactic peel | Lactice 20% solution (100ml) Quantity Price: $ 35.00 Quantity Strong Lactic peel | Lactic 30% solution (100ml) Quantity Price: $ 39.00 Quantity Papaya Enzyme | Salicylic acid, Papaya & Pineapple enzymes, rosehip oil & sea buckthorn oil (50ml) Quantity Price: $ 45.00 Quantity Papaya Enzyme | Salicylic acid, Papaya & Pineapple enzymes, rosehip oil & sea buckthorn oil (100ml) Quantity Price: $ 75.00 Quantity AHA/BHA Mask/paste | Glycolic acid 11.5%, lactic acid 3.8%, salicylic acid 0.7% (100ml) Quantity Price: $ 35.00 Quantity AHA/BHA Mask/paste | Glycolic acid 11.5%, lactic acid 3.8%, salicylic acid 0.7% (300ml) Quantity Price: $ 70.00 Quantity Proluronic Serum | Hyaluronic acid, Vitamic b3 & vitamin b5 (200ml) Quantity Price: $ 45.00 Quantity Proluronic Serum | Hyaluronic acid, Vitamic b3 & vitamin b5 (500ml) Quantity Price: $ 80.00 Quantity
