Customer/Account Information
Contact Name
*
First Name
Last Name
Phone Number
*
Email Address
*
example@example.com
Shipping Address and business information
Business Name
*
Name of contact that will coordinate delivery and training
*
First Name
Last Name
Phone Number for coordinating delivery and training
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Please write name of person or location that referred you
How do you plan on paying for your device(s)
*
Please Select
Pay with check or bank transfer
Pay with check or bank transfer (2 payments over 2 months)
Finance
Payment is due 3 weeks before delivery date
How soon are you wanting the machine(s) delivered?
*
Please Select
As soon as possible
1-2 months
3+ months
Anything else you would like to share with us:
Payment by Credit Card or Paypal
Deposit
*
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iLight IPL Deposit
This deposit will hold your iLight IPL device and will be put towards your total price.
$
500.00
Quantity
iLight LED Pro
This deposit will hold your iLight LED Pro device and will be put towards your total price.
$
500.00
Quantity
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
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