AC'CENTS Online Order Form

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Thank you for choosing Newport Medical Products, Inc. and the AC'CENTS system. Please fill out the below information accurately and provide a valid credit card number when placing your order. Thank you and feel free to email us with any questions.

NAME:
ADDRESS:
EMAIL:
COUNTRY:
CITY, STATE, ZIP
PHONE FAX
ORDERED BY: SPECIALTY
BILLING (if different)
NEEDED BY ANY SPECIFIC DATE?

LASHLINER PIGMENTS

Product Price Quantity
1201 - Gray $25.00
1202 - Black $25.00
1203 - Dark Brown $25.00
1204 - Med. Brown $25.00
1205 - Light Brown $25.00

CHROMA PIGMENT SERIES

Product Price Quantity
1220 - Chroma 0 $25.00
1221 - Chroma 1 $25.00
1222 - Chroma 2 $25.00
1224 - Chroma 3 $25.00
1225 - Chroma 4 $25.00
1226 - Chroma 5 $25.00
1227 - Chroma 6 $25.00
1228 - Chroma 7 $25.00
1229 - Chroma 8 $25.00
1230 - Rose $25.00
1231 - Deep Red $25.00

ACCESSORIES

Product Price Quantity
1620A - Color Palette $6.00
1210A - Petri Dish - Sterile $2.50
1365A - Dip Formed Sleeve $3.50
1101F - Foot Pedal $28.00
1101E - Extension Cord $9.00
1360A - Replacement Motorized Handpiece $1000.00

DISPOSABLE NEEDLE TIPS

Product Price Quantity
1352D - 3 Needle 26 Gauge Tip $35.00
1354D - 3 Needle 28 Gauge Tip $35.00
1356D - 7 Needle 28 Gauge Tip $47.00

NATURAL EYES

Product Price Quantity
NE752 - Triple Needle Tip $40.00
NE114-1012 - Angle Drive $500.00
NE114-1013 - Eva Head $300.00

AC'CENTS UNITS AND HANDPIECES

1301AV - AC'CENTS Motorized Variable Speed System w/ Handpiece $1750.00
1360A - AC'CENTS Motorized Handpiece $900.00
1301AVTI - Trade-In Competitive Equipment for AC'CENTS Motorized Handpiece $900.00
1301UP - Upgrade to Motorized V/Speed, including Handpiece $800.00

SHIPPING/PAYMENT INFO

UPS 1 DAY
UPS 2 DAY
UPS 3 DAY
UPS GROUND

PLEASE NOTE: IF YOU ARE NOT MEDICAL PERSONEL (HOSPITAL OR DOCTORS OFFICE) OR YOU LIVE OUTSIDE THE UNITED STATE, YOU MUST PAY BY CREDIT CARD. MEDICAL PERSONEL MAY LEAVE THE CREDIT CARD FIELD BLANK IF THEY WISH TO RECEIVE AN INVOICE. PLEASE CONTACT US IF YOU ARE UNSURE WHETHER OR NOT YOU QUALIFY AS MEDICAL PERSONEL. THANK YOU.

CREDIT CARD # EXPIRATION DATE (MM/YY)