Lira Clinical Order Form
"
*
" indicates required fields
Name
*
First
Last
Phone
*
Email
*
PRODUCTS:
*
PROLINE
PRO Exfoliating Cleanser -
$85
PRO Lite Serum with PSC -
$109
PRO Brite-Plus Serum -
$115
PRO Firming Serum with PSC -
$167
PRO Retinol Crème -
$175
PRO C4 Retinol Serum with PSC -
$160
PRO Brightening Masque -
$109
PRO Anti-Aging Pads -
$110
BIO LINE
BIO Enzyme Cleanser -
$85
BIO Hydra C Serum with PSC -
$140
BIO Hydra Infusion with PSC -
$120
BIO Lift Crème with PSC -
$175
BIO Caviar Crème with PSC -
$175
BIO Hydrating Mineral Masque -
$94
BIO Hydrating Mineral Mist -
$55
BIO Lip Factor -
$46
MYSTIQ LINE
MYSTIQ iLuminating Cleanser with PSC -
$85
MYSTIQ Perfecting Eye Crème with PSC -
$125
MYSTIQ iLuminating Polisher with PSC -
$80
MYSTIQ Intense C 15 Booster with PSC -
$185
MYSTIQ iLuminating Beauty Oil with PSC -
$145
ICE LINE
ICE Sal Cleanser with PSC -
$85
ICE Clarifying Scrub with PSC -
$85
ICE Refining Masque with PSC -
$85
ICE Clarifying Treatment with PSC -
$90
ICE Balancing Lotion with PSC -
$90
ICE Clear Stick Acne Spot Treatment -
$57
Delivery or Pick Up
*
Please select
Delivery
Pick Up
Address
*
Street Address
City
State
Postcode
Phone
This field is for validation purposes and should be left unchanged.