Lipoderma Order Form

Quantity (5) 1.5ml vials

$2500

Quantity (10) 1.5ml vials

$4500

Step 1

Step 2

Lipoderma Quantity (#LIP0175)*

Date Needed*

Physician Name*

Facility Name*

Billing Email*

Shipping Address*

City*

State*

Zip*

Representative Name

Representative Email Address*

Distributor*

Notes

All orders are shipped overnight for delivery, shipped cold, packaged in a 48-hour shipper.
The cut-off for same-day shipping is 1:30 pm EST.
Orders placed on Friday will be shipped on Monday for Tuesday delivery.