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Services Order Form:

Please click the box next to the items that you are ordering (If you want multiple copies or sets, you can indicate that in the Special Message box at the bottom of the page)

SERVICES
Please click the box next to the service that you are ordering

COUNSELING SESSION ($70.00)
HAIR ANALYSIS PACKAGE ($375.00)
HAIR ANALYSIS 90-DAY UPDATE ($195.00)



CLIENT CONTACT INFORMATION
Name:
Address:
Address/Apt #
City:
State:
Zip:
Email:
Phone:


PAYMENT INFORMATION (To expedit your order, you can send your payment information now. We will send a confirmation with the total including shipping. Our e-mail is encrypted. If you prefer to send a cashier's check or money order, please indicate in the Special Message box below.)
Payment Type:
Credit Card Number:
Expiration Date:

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