Instructions for activating this Gift Certificate:
  1. Print this page
  2. Fill out the name of the beneficiary on line 1 "A Gift For"
  3. Fill in the amount of your gift on line 2
  4. Fill in your name on line 3
  5. Fax it to our office at: (718) 409-4900
  6. Call the office with you credit card information, or
  7. Enclose this page in an envelope along with your check or
credit card information and mail to us at:

                            The Chiro Loft
                            Attn: Gift Certificate
                            1476 Williamsbridge Road
                            Bronx, NY 10461

Be sure to provide us with your address and we will mail your activated Gift Certificate back to you. Be
sure to allow ten (10) business days for processing and handling. If you need us to expedite the process
in order to make a deadline for a holiday, birthday, or other special occasion, make sure you mention it in
your fax or discuss it with our staff when you call. Fill in the required information below:

Your Name:___________________________

Your Address: _________________________

            _________________________

Telephone: ___________________________

Email:________________________________

Name Of Patient:________________________     

Method Of Payment: (choose one)

  1. Check number ___________________ in the amount of $___________
  2. Credit Card:    Visa        Master Card        Amex        (circle one)
  3. Name As It Appears On Credit Card (Printed):______________________
  4. Credit Card Number: _________________________________________
  5. Expiration Date:_____________________________________________
  6. Mailing Address Associated  With This Credit Card:

                                 _______________________________________

                                 _______________________________________

I certify that the information provide here within is accurate to the best of my knowledge. I give The
Chiro Loft my permission to charge my credit card noted above the amount indicated in line 1 under the
heading "Method Of Payment."



Authorized Signature: _________________________________

               Date:__________________________________



Feel free to address your questions to: The Doctor via email to: info@thechiroloft.com

Back
Gift Certificate                

A Gift For _____________________________________

Worth________________________________Dollars $__________

Authorized By__________________________Expires ___________
Gift Certificate Record

To:______________

Amount:__________

From:____________

Date:_____________

Issued By:__________