Fax ordering

Kindly complete the form in black pen to ensure that the fax comes out clearly, and fax it through to Dermaxime, our holding company at 00 27 12 361 0061. (The South African dialing code is 27)

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Type of credit card - tick box

 

Visa

 

MasterCard

 

Amex

 

Diners

Expiry date of card

Year                                       Month   

Your Name & Surname 
(As printed on the card)

 

Credit card number

 

CVV number 
(the last three numbers printed on the back of your card - normally on the signature strip)
 

e-mail address

 

Shipping address

 

 

 

City

 

State/Province

 

Zip code  &   Country

 

Telephone #

(                )

Skincare and grooming Items 

1.

 Cellumend

US $

 

2.

 

US $

 

3.

 

US $

 

4.

 

US $

 

5.

 

US $

 

6.

 

US $

 

TOTAL

US $

Special instructions

 

 

Your signature

 

 

Information supplied is for general information purposes only and no statements have not been evaluated by the 
FDA or the S. A. MCC and no information supplied is intended to diagnose, treat, cure or prevent any disease.
© Copyright Dermaxime (Pty) Ltd 2001 - 2010.
 The entire content of this website is copyrighted - including text, photographs, logos, metatags etc., and no part
 whatsoever may be copied and used - privately, for educational purposes or publishing or for commercial application - without
 the written permission of Dermaxime (Pty) Ltd.
Cellumend™
Our site is maintained and was last updated on 4 March 2010.