WE ARE STANDING BY. 33403 * 33404 * 33407 FLORIST. 561-776-8630.

OPEN 7 7 7. LAKE PARK, RIVIERA BEACH, WEST PALM BEACH 33403 * 33404 * 33407

**PLEASE PLEASE READ: Upon completion of this order form you must TEXT the word "SEND" to 561-776-8630. **OPEN 7 DAYS. **We are standing by. **We are here for you. **WE DELIVER WITHIN 2 HOURS AFTER YOU PLACE YOUR ORDER. **TEXT the word "SEND" to 561-776-8630 FOR SAME DAY FAST SERVICE.

Sender Information:

What zip code are the flowers going to? If the zip code is not listed, please call 561-776-8630.

*

33403

33404

33407

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Delivery Information: Upon completion of this order form you must TEXT the word "SEND" to 561-776-8630.

Delivery Date: * +

Delivery Time: *

Select Bouquet. SELECT BY PRICE FOR SPECIALTY BOUQUETS.

WE WORK WITH YOUR BUDGET. YOU CAN AFFORD TO SEND FLOWERS!!

Roses and mixed floral are fresh daily and are while supplies last.

WE WILL DO AN EXCELLENT JOB FOR YOU. We truly care about the sender and recipient.

PRICES INCLUDE TAX AND DELIVERY. WE QUOTE TOTAL PRICES. No delivery charge.
Please go to www.dialarose.com/photos to see pictures of the bouquets. Call 561-776-8630 for more information or to place a custom order. *

WE CAN HELP WITH ANY ORDER.

PLEASE CALL!! 561-776-8630

Recipient Information:

First Name *

Last Name *

Business/Community/Building Name (if applicable)

Street Address *

Apartment or Suite Number

City *

State *

Zip Code *

Phone Number *

Is this a gated community? *

If Yes, please enter a gate code, if available

Should we call the recipient before we deliver? *

If the recipient is not at home, may we doorstep? *

Message Card: Your message card is so important. It will read exactly how you put it in the box. Please be sure and sign it if you want your name on the card.

What would you like your message card to read? What is the occasion? PLEASE BE CERTAIN TO SIGN THE CARD AS YOU WANT IT SIGNED: For example: Love, Pookey. ***YOUR MESSAGE CARD will help the designer make your bouquet customized!! *

ANONYMOUS BOUQUETS. Please be advised. ***No signature means NO DISCLOSURE.*** Anonymous Bouquet Disclaimer. ****Disclaimer. Any anonymous bouquet order will be kept confidential and no information will be given to anyone who calls, sender or recipient. WE DO NOT DISCLOSE ANY INFORMATION TO ANYONE FOR ANY REASON, SENDER OR RECIPIENT, FOR ANY ANONYMOUS BOUQUET. IS THIS BOUQUET ANONYMOUS?? YES OR NO. PLEASE ADVISE.

Special Instructions (Optional):

Please enter any special instructions. 1) Special time?? 2) Delivery landmarks?? 3) Significant color of roses requested??

Credit Card Information: Mastercharge, Visa, American Express, Discover.

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Code. PLEASE PROVIDE SECURITY CODE IN THE BOX BELOW. ALSO, PLEASE READ: Upon completion of this order form you must TEXT the word "SEND" to 561-776-8630 for your ORDER CONFIRMATION. Thank you for trusting our fine service. *