Product Reorder

Product Reorder Form - For Current Medical Skin Care Patients of the Center for Eye & Laser Surgery Only.

All of our skin care products are to be used under medical supervision. If you have not been under Dr. Pacheco’s care and using our medical skin care products, please schedule your initial consultation by calling our office at 410.647.0123.

If you have not been seen by Dr. Pacheco for your follow-up skin care appointment in the last six months, we may ask you to schedule an appointment prior to filling your product reorder to review your progress and to make any adjustments necessary to your skin care regime.

For your personal identity security, we will not accept credit card numbers except by telephone or in person. DO NOT INCLUDE YOUR CREDIT CARD NUMBER IN THIS FORM. We will need to contact you via telephone in order to complete the processing of your order. We accept Visa, MasterCard, debit cards, checks and cash. You will be charged a shipping and handling fee for mail orders.

Please allow 24 to 48 hours for our office to contact you to complete your order.

First Name:

Middle Initial:

Last Name:

Best Contact Telephone #:

Alternate Telephone #:

Best time to contact you:

Pick up at our office

Mail

Shipping Address:

Products Needed:
(Please write the exact name of the product and fluid oz. as it reads on the product container.)

We thank you for allowing us to be part of your health care.