Pinnacle Point -Luvigix Order Form
Note: For recurring orders, this process applies once the New Account Form and Credit Card Authorization Form have been completed and the account has been activated. *Please ensure all sections of this order form are completed in full—incomplete forms cannot be processed or fulfilled.
Physician's name as it appears on medical license:
First Name
Last Name
Company Legal Name:
Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (for provider):
Cell Phone (for provider) for verification *not landline for business :
Representative Name:
Representative Email:
Order Quantities:
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ReviveX Starter Pack
x2 Boxes, Free Marketing*
$1,600.00
$
1,600.00
ReviveX
1-5 Boxes
$800.00
$
800.00
Quantity
1
2
3
4
5
6
7
8
9
10
ReviveX
6+ Boxes
$785.00
$
785.00
Quantity
1
2
3
4
5
6
7
8
9
10
Flat Fee Shipping
$125.00
$
125.00
Quantity
1
2
3
4
5
6
7
8
9
10
Patient Trifolds Skin
x20 per bundle, includes shipping
$40.00
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Patient Trifolds Hair
x20 per bundle, includes shipping
$40.00
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Juvasonic Starter Pack
$4,125.00
$
4,125.00
Quantity
1
2
3
4
5
6
7
8
9
10
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