For Medical Professional use only
Date
*
-
Month
-
Day
Year
FOR OFFICE USE ONLY
1,4 - Benzenediol Micronized Cristal 6% / Niacinamide 4% / Glutathione 1% / Bisabolol 1%
Physicians Information
*
Presciber Signature
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Use the address associated to your Professional XTETIC account. Any other e-mail address will not let you purchase the Complexion Code Boost.
Submit
Should be Empty: