Instant Laser Hair Removal Consultation

HairLasers.com Register Your Clinic

Listing Information -  – please submit a different form for each clinic that you would like to list. Fill out this form online or click here for PDF to out and print this form and then fax it back to 561-246-3416. Business customers call 561-445-6673.

* - indicate required fields
Listing Information
*First Name
*Last Name
*Business Name
*Physician / Laser Hair Removal Contact
   
*Address
*City
*State

*Country

*Zip Code
   
*Telephone
( ) - -
*Fax
( ) - -
   
*Email Address
Web Address
   
Billing Information
Check if Billing contact is same
*First Name
*Last Name
*Business Name
*Physician / Laser Hair Removal Contact
   
*Address
*City
*State

*Country

*Zip Code
   
*Telephone
( ) - -
*Fax
( ) - -
   
*Email Address
Web Address
   
Credit Card Information
* You will not be charged until you listing is made active. Listings require review prior to approval for activation.
*Credit Card Type
*Credit Card Number
*Credit Card Expiration
/
*Credit Card CVV Code
   

I would like to sign this clinic up for $50.00 per month for the first listing plus $25 per month for each subsequent listing for this clinic on (place check next to each):

www.HairLasers.com
www.CelluliteUsa.com
www.Face-Lasers.com
www.Vein-Lasers.com
www.CelluliteWorld.com

*   I agree to billed automatically, in monthly recurring payments. I understand if I want to cancel my subscription, please notify us via fax or email (info(at)HairLasers.com) before your next billing cycle.



Signature: ________________________________________


Print Name: ________________________________________


Date: ________________________________________


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