Order Request Form

Name

Email

Phone

Requested Order Date (YYYY-MM-DD)

Picking Up or Delivery

Requested Pick Up/Delivery Time

Delivery Address (If Applicable)

Quantity of Each Item Selected Above

Would you like to add disposable eating utensils to your order – $2 per cutlery set? (If yes, enter quantity below)

Would you like to add 6-inch disposable bamboo plates to your order – $1 per plate? (If yes, enter quantity below)

Is This Order for a Special Occasion? If Yes, Tell Us More!

Do You or Anyone Partaking in This Order Have a Food Allergy or Dietary Restriction? If Yes, Please Explain. If None, Type None

Payment & Cancelation Policy: Once your order has been accepted, payment is due within 7 days unless otherwise listed on your invoice. We reserve the right to cancel any order in which payment isn’t received by the invoice due date. You may cancel up to one week prior to your pick-up/delivery date for Store Credit Only. No refund will be given for orders canceled less than one week prior to your pick-up/delivery date(required)

I have read & agree to the Payment & Cancelation Policy

Food Allergy Statement: Please be advised that our menu items are not prepared in an allergen-free environment and may contain or come in contact with the following ingredients: Milk, Eggs, Wheat, Soy, Peanuts, Tree Nuts, Fish and/or Shellfish, etc. While we make every effort to shield orders with food allergy or dietary restrictions, we cannot guarantee that any order will be 100% free of allergens. Customers concerned with food allergies or dietary restriction should be aware of this risk. Betty Bloom’s, LLC will not assume liability for any adverse reactions caused by food consumed (required)

I have read & agree with the Food Allergy Statement

How Did You Hear About Us?

Enter Discount Code Below (If Applicable)

Thank you!