DERMAL SOURCE ORDER FORM
1017 SW Morrison Street, #210, Portland, Oregon 97205
Phone: 866-568-3223, Fax: 503-973-5433, www.dermalsource.com
To download a pdf of this order form "right-click here" and choose "save target as"
PRODUCT DESCRIPTION |
QTY |
UNIT PRICE |
TOTAL |
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Blue Gel Anesthetic – 1 oz. For use during procedures – reduces swelling and bleeding |
$ 40.00 $ 288.00 (12) W |
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Super “T” – 7/8 oz. Preprocedure topical anesthetic cream containing lidocaine, tetracaine and benzocaine |
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$ 35.00 $ 252.00 (12) W |
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Pro Plus – 7/8 oz. Preprocedure anesthetic cream containing lidocaine and tetracaine |
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$ 35.00 $ 252.00 (12) W |
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| Laser Anesthetic Cream - 1oz. Developed for the laser industry this 2% tetracaine, 4% lidocaine and 12% benzocaine product is an excellent predeadener for everything excluding eyeliner. |
$ 72.00 |
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| Vasocaine – 4 oz. This 5% lidocaine spray anesthetic is the most powerful level of anesthetic available over-the-counter anesthetic that is SAFE FOR USE IN ALL TYPES OF BROKEN SKIN PROCEDURES. | $ 30.00 | ||||||
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SJ3– 4 oz. Liquid anesthetic spray for use during all but eyeliner procedure, and for cleaning the skin and removing predeadeners prior to procedures |
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$ 40.00 $ 300.00 (12) W |
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SJ3 – One ounce squeeze bottle |
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$ 20.00 |
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4 Pack sampler – One each of Super “T”, Blue Gel Anesthetic, Pro Plus and one ounce SJ3 |
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$ 100.00 |
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Zone 1 – 7/8 oz. – Preprocedure topical anesthetic cream containing lidocaine Must order quantity of 5 for special |
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$ 10.00 Special $ 228.00 (12) W |
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Zone 2 – 7/8 oz. – Clear gel for use during procedures – reduces swelling and bleeding |
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$ 35.00 $ 252.00 (12) W |
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“In the Zone” 2 pack containing Zone 1 and Zone 2 |
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$ 50.00 |
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Saline Wound Wash – 7 ounce spray |
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$ 10.00 |
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Barrier Film (1200 4 x 6 sheets) |
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$ 24.00 |
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Headrest Covers (250/pack) |
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$ 16.00 |
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Tube Sleeves – 1200 feet of 2” tubing |
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$ 25.00 |
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8 ounce Squeeze Wash Bottle |
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$ 8.00 |
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16 ounce Squeeze Wash Bottle |
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$ 10.00 |
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Freshen-Up – sterile, individual 8-1/2” x 11” non-alcohol wipes for use before, during and after procedures. 100/box |
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$ 20.00 |
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Sterile Mouth Guards – for lip procedures – package of 5 |
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$ 30.00 |
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Permanent Cosmetics permanent makeup brochure – graphic “Three Ethnic Women” cover (50) |
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$ 30.00 $ 180.00 (12) W |
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Pigment Reference Manual |
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$ 20.00 |
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Total Pigment Sales from Back of Form |
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$ |
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SUBTOTAL |
$ |
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Shipping and Handling - $8.00 for ground orders under $100, $14 for ground orders between $100 and $200. Call for rates on orders over $200, 2nd day, 3rd day, overnight and other special deliveries. International rate $40. Canadian rate $20. |
$ |
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TOTAL |
$ |
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Payment Methods: Cash, Money Order, Check, Visa, Mastercard, Discover, Am Express |
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SORRY – NO C.O.D. DELIVERY
Name________________________________________
Expiration Date___________________________
Address_____________________________________
Name on Card______________________________________________________________________
Signature________________________________
City, St, Zip___________________________________
Phone:______________________________________
Fax:________________________________________
Email Address:_______________________________
DERMAL SOURCE
1017 SW Morrison Street, #210, Portland, Oregon 97205
Phone: 866-568-3223, Fax:
503-973-5433, www.dermalsource.com
To download a pdf of this order form "right-click here" and choose "save target as"
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PRODUCT
DESCRIPTION |
QTY
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UNIT PRICE |
TOTAL |
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BROW
COLORS: |
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Blonde
Pigment – 2 ounce |
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$ 25.00 $ 144.00 (12) W |
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Chestnut
Pigment – 2 ounce |
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$ 25.00 $ 144.00 (12) W
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Taupe
Pigment – 2 ounce
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$ 25.00 $ 144.00 (12) W |
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| Dark Walnut Pigment – 2 ounce
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$ 25.00
$ 144.00 (12) W
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Brow
Warmup - to warm up gray brows –
2 ounce |
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$ 25.00 $ 144.00 (12) W |
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SKIN
DEFINERS: |
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Caucasian
Skin – 2 ounce |
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$ 25.00 $ 144.00 (12) W |
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Breast
Rouge – areola/nipple color - 2 ounce |
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$ 25.00 $ 144.00 (12) W |
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LIP
PIGMENTS: |
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Neutral
Lips – our most natural color – 2 ounce |
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$ 25.00 $ 144.00 (12) W |
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Warm
Lips – our most popular – 2 ounce |
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$ 25.00 $ 144.00 (12) W |
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Cool
Lips – cool rose to offset sallow skin – 2 ounces |
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$ 25.00 $ 144.00 (12) W |
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Lip
Riche – deep garnet with no blue tones – 2 ounces |
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$ 25.00 $ 144.00 (12) W |
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Lip
Line Corrector – lightens and warms dark lip lines – 2 ounces |
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$ 25.00 $ 144.00 (12) W |
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Lip
Warmup – to warm a too cool lip tone – 2 ounces |
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$ 25.00 $ 144.00 (12) W |
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Set of All Six Lip Pigments
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$ 120.00 |
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Set of All Five Brow Pigments
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$ 100.00
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TOTAL PIGMENT SALES (List on Front of Order Form) |
$ |
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Dermal Source must be notified of
damaged products within ten (10) days of receipt of shipment. There will be a 10% restocking fee on
any unopened products that are returned within ten days of receipt. After ten (10) days, no products will be accepted for return regardless of condition. Full ingredients are listed on every
pigment and anesthetic. MSDS
Sheets are available upon request or can be downloaded from the “Documentation”
page at www.dermalsource.com.