(GIFT CERTIFICATES AVAILABLE)

Please submit your information below to hold your requested appointment date and time for your selected location for SMOKING CESSATION TREATMENTS ONLY.  Credit cards are charged immediately upon receipt of your scheduled appointment.  Cancellations must be received 7 days prior to scheduled appointment time for full credit of amount charged.  If your requested date and time are not available, LaserCare will NOT charge your card.  Furthermore, LaserCare will notify you within 48 hours of your submission or within 48 hours of the scheduled appointment time, whichever is sooner.  LaserCare will not accept any registration submitted less than 7 days prior to requested appointment time without prior approval.  Please call the number below if you wish to schedule an appointment within 7 days.  LaserCare will not accept any form not completely filled out.  LaserCare reserves the right to cancel any location prior to scheduled appointment times for that location with a full refund to you.  Submitting information to LaserCare via this form is not acceptance of payment.  By submitting the information below you agree to the charge of 397 for your smoking cessation treatment .  Discounts available for referrals and small groups. Please call 866-515-QUIT (7848) for more information or 866-586-STOP (7867) extension 1 to schedule your appointment by phone.

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Choose one of the following options:


Choose one of the following options:

          Choose one of the following options:

Must have valid e-mail address for PayPal Invoice

PLEASE FILL OUT THE FOLLOWING INFORMATION IF NOT USING PAYPAL INVOICING

Please provide the following ordering information:

BILLING
Street Address #
Account Name

        Credit Card Number


        Expiration Date


        CVC Authorization


        By typing my initials below along with indicating the amount to be charged, I authorize LaserCare to charge my account for the amount I have specified and initialed.  I understand that if I do not cancel more than 7 days prior to my appointment time, LaserCare may not refund any portion of the cost of the treatment. Please note any special needs in this box.




Copyright © 2008 CSD&B, INC. DBA:LaserCare.  All rights reserved.
Revised: 02/02/09