Secure Online Credit Card Payment Delivery Form
 Purchase your spa Chakra gift certificate for that someone special Gift Certificates can be used towards any of our Spa or Salon services Appointments required.  
Fields marked with an asterisk (*) are required
Gift card Amount:        
Number of Cards:
Name for gift card recipient:
Delivery address for Gift card:  *
City:  *
State: *
Zip: *
Country: *
Purchaser Information:
Name as it appears on card: *
Billing address: 
 *
Billing address and purchasers name must match the credit card number provided, if it does not match the credit card will get declined.
City: *
State: *
Zip: *
Country: *
Email: 
 *
IMPORTANT: your payment confirmation receipt and transaction number will be sent to this email address.
Home Phone: *
Business Phone:
Mobile Phone:
Delivery options for gift card: *
Delivery notes: Spa Chakra & Salon is not responsible for any lost gift certificates using the regular mail option.  We strongly recommend delivery using Federal Express or picking up the gift card in person.
Comments or concerns?
(Maximum 225 characters)
Credit Card Information
Name on credit card: 

 *
Enter your name as it appears on your credit card.
Card type: *
Card number: *
Expiration date: / *
Amount:


$ U.S. Dollars *
Include comma and decimal point.
Enter your name again for digital confirmation:

 *
I acknowledge charges described hereon. Payment in full to be made when billing or in extended payment in accordance with standard policy of company issuing the card.

Important notice: Please carefully review your entries for accuracy and when satisfied click the "Submit" button below or "Reset" to clear ALL entries. Please be sure to ONLY push the submit button once, if pushed more than once your card may be charged multiple times.
  I hereby authorize Spa Chakra & Salon LLC to charge my card for above charges.

I UNDERSTAND THAT THESE CHARGES ARE NON-REFUNDABLE AND THAT GIFT CARDS HAVE NO CASH VALUE AND CAN ONLY BE USED TOWARDS SPA OR SALON TREATMENTS AT SPA CHAKRA AND SALON. AND I SPECIFICALLT DISCLAIM MY RIGHT TO CREATE A CHARGEBACK FOR THE ABOVE REFERENCED CHARGES. (GIFT CARDS ARE VALID FOR 1 YEAR).