Mini Mods Online Enrolment Form
Name:
*
First Name
Last Name
Company / Clinic / Salon
Phone Number
*
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Discount Code
Payment
Mini Mods Online programmes I would like:
*
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Fractional Laser
$
199.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Understanding and Treating Melasma
$
299.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
NZ Regulations for IPL & Laser
$
199.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Treating Transgender or Gender Reassignment for Hair Removal
$
89.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Safety for Pregnancy with IPL & Laser
$
199.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Signature to accept Terms & Conditions, Protection of Intellectual Property and Non-disclosure Agreement of Enrolment:
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