Gift Certificate Request Form

*Please note that in-person services are only for women who have a breast cancer diagnosis or history.

Gift certificates can be purchased for in-person* standard or custom amounts. Please fill out the form below and I will reach out to confirm the details and arrange payment and pickup/delivery.

NOTE: Before buying a gift certificate for an in-person massage it is best to find out if the person will indeed like and use this gift. Not everyone is comfortable receiving hands-on bodywork especially during a challenging time like a cancer experience. If you are unsure I suggest purchasing an “Ask Amy” consultation as a gift instead as these are easer to schedule and often more useful to someone newly diagnosed or in treatment.

Recipient's Name:

As you would like it to appear on the gift certificate.

First Name

Last Name

Your (Giver's) Name:

As you would like it to appear on the gift certificate.

First Name

Last Name

Your Email:

Please provide the email for the contact handling the gift certificate.

Your Phone:

Please provide the phone number for the contact handling the gift certificate.

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Gift Details:

Please select one option from the dropdown menu. If selecting custom please enter the amount in the next field.

Custom Dollar Amount

Please add the amount you would like to give if not opting for a preselected amount.

Method of Delivery:

Please select how you would like to handle pick up/delivery

Office Pick Up (493 Delaware Ave, Buffalo, NY 14202)

USPS + $8 S&H (mailed directly to the recipient)

Email (digital copy only)

Recipient's Mailing Address (for mailed paper certificate)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Recipient's Email (for emailed digital certificate)

Preferred Payment Method:

Please select how you would like to pay.

Venmo @Amy-Hartl-LMT

Credit Card via digital invoice

Cash (in-office pick up only)

Special Message or Additional Note:

Please share any additional information, questions, or requests, or if you would like to add a special message for the recipient.

Gift Certificate Request Form

Personalized support and practical self-care strategies for helping breast cancer survivors regain comfort, confidence, and control over their bodies.