Credit Card Billing Authorization Form

I authorize Bay Area Cosmetic Dermatology to charge the account indicated below every 90 days for the payment of my quarterly BACD Auto Ship. By signing this agreement I understand the charges associated with my quarterly shipment. Additionally, I understand that I will receive free shipping and can cancel at any time. If I do not cancel, I will continue to receive the products as specified in this contract on a quarterly basis. Once I have been charged $3,000 or more, I will earn a $250 gift card which may be used on esthetician services or laser services with a nurse (includes Vbeam, IPL, pigmented lesions, Clear + Brilliant, excludes any Fraxel treatments)


Please input the address you would like to receive the products.
Is your billing address different from your shipping address? *

Choose Your Products

I agree these are the products I would like to have sent to me quarterly (every 90 days). Please fill in each row with your desired product name.
Can't remember the names or prices of your favorite products?
Give us a ring (415) 292-6350 
OR
Visit our web store to search our inventory.
 

When would you like to receive your first shipment of products? *

Payment Information

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Visa

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Sign Below & Hit Submit

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