Order Form

Care Providers' Referrals Exchange (Printable Websites)

 How to use this Form:
Use one Order Form per client
Type in the Form, on screen response, (complete applicable blanks). 
Press "TAB" to move between blank spaces. 
DO NOT press the  "BACK" button because all information will be deleted if you leave this web page.

I would like to order the design of a Care Providers' Referrals Exchange printable web site from the following website:

Building dditional printable websites:
Please send a list of their Internet addresses by E. Mail to:

Services :

Develop the care providers' referrals websites from the Internet addresses of above web pages provided by the client.  Their features are the following:

  1. The website address (bottom of the page) will have the client's name and the care provider's name. Example
  2. Left column is reserved for the care provider who approve its contents typically taken from his/her website.
  3. Right column is reserved for the client who approve its contents typically taken from his/her website.
  4. The client may order multiple printable websites to develop a "NETWORK" of providers/client' websites.

Fees :

  • Special Fees: $195 per printable website (regular fee $250)
  • Your Order: $195  per printable website X Number of care providers' websites = $


    1. Checks only, no credit cards.
    2. Orders are paid in full and in advance
    3. Check Number
    4. Payment Date 

Name And Contact Information:

First Name M.I.   Last Name
Business Name
Number & Street  Suite #
City     State     Zip Code
Area Code   Telephone     FAX  
E-mail Address
Web Site URL

Sending The Order Form .
Please complete, then print the Order Form and mail it with your check to:

Doctors' Marketing Service
P.O. Box 748 , Lake Forest, California 92609-0748

E. Mail  affluentpatients@gmail.com

copyright© 2018  Doctors Marketing Service