PRINT OUT AND FAX TO 703-752-4076                                                          

Please select the quantity and total the amount in the column provided. Include a check, money order, or credit card information and we will send you a receipt with the gift certificate to the address as indicated on the order form. If you have any questions please do not hesitate to contact our office at 703-752-4078 and ask to speak with Tracey .

These prices are all inclusive. No additional fees. Please give us the address you would like your gift certificate and receipt mailed to: 

Recipient of Gift Certificate:	Your Information:
Name:	Name:
Address:	Address:
City/State:	City/State:
Zip:	Zip:
Phone:	Phone:
	Email:
	Can we leave a message at this number?    Yes  /  No
Ship Gift Certificate to above address? Yes  /  No	Ship Gift Certificate to above address? Yes  /  No

If this is a special occasion, please indicate a personalized greeting you would like to include on the gift card.

Please include your phone number and email for any questions we may have to clarify your order. If this is a surprise gift and you prefer no message to be left at this number, please indicate by circling a response.

Payment Information
Check or Money Order enclosed and made payable to:  Tri Therapeutic Massage

Credit Card Information. Please circle: MasterCard/Visa    Credit Card Number:______________________________  Exp Date:___/___/___ 
Name as it appears on the Credit Card:__________________________________
Cardholder's signature:_______________________________________________

Print out, complete form and fax to 703-752-4076 or mail to: Tri Therapeutic Massage 2112 A Gallows Road Vienna, Virginia 22182

for office use:
_______ GC #
_______ Date sent _______ initials 

rev. 11.2.04trimassage.com

 Massage Therapy for Vienna Virginia.  Copyright 2002 Tri Massage