Optometric Aesthetics

Customer/Account Information

Contact Name*

First NameLast 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 NameLast Name

Phone Number for coordinating delivery and training*

Office Name*

Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Closest Airport to Office

How did you hear about us? *

OA Ambassador (Who answered your questions about OA and devices)*

OA Ambassador (Who helped answer questions and influenced your purchase, select all that apply)*

Enter a percentage beside each name to equal a total of 100%*

How do you plan on paying for your device(s)*

Payment is due on delivery date

How soon do you want the machine(s) delivered

Payment by Credit Card or Paypal

Anything you would like to share with us.

Deposit*

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

Total

$0.00

Credit Card

Apple Pay

Google Pay

Cash App Pay

Please let us know who had an impact in your decision to purchase your device/s: