Name *

First Name

Last Name

Please choose your Pre-Numbing AND During Procedure items required

I require the complete 2mLs of Pre-numbing AND 1mL of During numbing

I require 2mLs of Pre-numbing ONLY (I already have arrangements for During numbing)

I require 1mL of During numbing ONLY (I already have arrangements for Pre-numbing)

I require another amount eg Skin Needling/CIT - I will note details in the additional remarks area below

Pregnancy/Breastfeeding *

I am NOT pregnant and/or breastfeeding

I am pregnant and/or breastfeeding and will note details in the extra remarks below

PAYMENT OPTIONS

Please note: all numbing products are sourced and paid for directly with the pharmacy. Please allow 72 hours during compounding hours for your order to be ready. You will be contacted by the pharmacy once your order is completed and ready to go. Please select the option you would like to use to confirm receipt of your numbing:

I will collect and pay for my order from Shop 1, Rivergum Village, 538 Plenty Road, Mill Park, VIC 3082 when it is ready.

Please call me to arrange over the phone credit card payment for my numbing to be delivered to my home address. I understand there will be an additional $14.95 for Express Postage. It will be my responsibility to ensure I bring my numbing on the day of treatment.

Please call me to arrange over the phone credit card payment for my numbing to be delivered directly to Cosmetic tattooing by Tuduyen (CTx2DN) 10 South Road, Airport West, VIC 3042 where it will be ready for me on appointment day. I understand there will be an additional $14.95 for Express Postage.