Optometric Aesthetics
Deposit Form
Customer/Account Information
Contact Name
*
First Name
Last Name
Phone Number
*
Email Address
*
example@example.com
Shipping Address and business information
Business Name (for sales agreement and invoice)
*
Name of contact that will coordinate delivery and training
*
First Name
Last Name
Phone Number for coordinating delivery and training
*
Office Name
*
Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Closest Airport to Office
How did you hear about us?
*
OA Ambassador (Who answered your questions about OA and devices)
*
Please Select
Collin Gray, OD
Michael Chism, OD
Sarah Terlesky, OD
Seth Roth
OA Ambassador (Who helped answer questions and influenced your purchase, select all that apply)
*
Mike Chism, OD
Collin Gray, OD
Alex Elson, OD
Seth Roth
Sarah Terlesky, OD
Please let us know who had an impact in your decision to purchase your device/s:
Enter a percentage beside each name to equal a total of 100%
*
How do you plan on paying for your device(s)
*
Please Select
Pay with check or bank transfer
Finance
Payment is due on delivery date
How soon do you want the machine(s) delivered
Please Select
As soon as possible
1-3 months
3+ months
Payment by Credit Card or Paypal
Anything you would like to share with us.
Deposit
*
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iLight IPL Pro + New advanced iLight handle Deposit
This deposit will hold your iLight IPL Pro 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
iLight LHR Pro (Laser Hair Removal)
This deposit will hold your iLight LHR 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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