Lip Contours Fax/Mail Order Form

Name: _____________________________________________

Address: ___________________________________________

__________________________________________________

__________________________________________________

City/State/Zip_______________________________________

Telephone: _________________________________________

E-mail: ____________________________________________

Quantity of Lip Contour Kits ordered: ____________________

Shipping and Handling -- $3.00 for first kit, $2.00 for each additional kit

Sales tax (FL residents only – add 6.5%): _________________

Grand total: _________________________________________

You may fax your order to 561-736-9520

Please mail this form with your check or money order enclosed for your grand total, payable to The Lip Lady at:

The Lip Lady
9727 Sun Pointe Drive
Boynton Beach, FL 33437

Please allow 2 – 4 weeks for delivery. Thank you for your order.