Valentine's Day Order Form

If you are out-of-town or unable to visit Power Flowers to purchase Valentine's Day flowers, please complete this form. Power Flowers will contact you to confirm the order, and obtain other necessary information.

Please make sure you provide a telephone number so that we can contact you. Do not specify credit card information on the form. Power Flowers will obtain this information from you over the telephone.
Your Name and Contact Information
Name:
Phone: Area Code: Number:
E-mail:
Purchase Information
Please indicate the item(s) you want to purchase.
Roses: Amount:
  Colour:
    Long stem: Short stem:
Floral Arrangement:
or
Gift:
Message
Please specify the message that you want to provide on the card.
Message:
Pick-up or Delivery Information
Please indicate whether you want to pick up the order from our store location or have it delivered. If delivery is desired, please provide the requested delivery information (minimum $35 order required for Valentine's delivery).
Pick-up: Delivery:
Recipient Name:
Recipient Phone: Area Code: Number:
Full Delivery Address:
City/Town:
Pick-up or Delivery Date:
Pick-up or Delivery Time*:
* Power Flowers will make every effort to deliver within the specified time frame. However, due to order volume, delivery on the specified day may be earlier or later.
Comments
Please specify any comments or directions to Power Flowers that will help us to satisfy your order.
Comments:
 
Submitted information will only be used by Power Flowers for the purpose of completing an order. The form will be sent to Power Flowers by Response-o-Matic.