Purchase a Gift Certificate

Your Name (first and last) *

Recipient's First Name

Recipient's Last Name

How would you like the recipient to receive this gift certificate? *

Send it to me

Send to recipient

Please fill out the fields below as you would like them to appear on the gift certificate. Fields left blank will be omitted from the gift certificate.

To:

From:

Amount:

Message:

Collect Payment *

$ 125

$ 200

Other amount

This gift certificate will be applied to the account of the recipient named in this form. Refunds are not made available for gifted services; transfers can be made upon request. An expiration date of one year from the date the gift certificate will be established and included on the certificate. This value of the gift certificate may be used to purchase services through Ithaca Myofunctional Therapy, LLC.

I consent to these terms and conditions that apply to the purchase of the gift certificate.

Signature *

Clear