Order Form for Predesigned Website

Order Form for Predesigned Website

Process:
[Processing your order takes 3 steps]
(1) First, fill out the form below and click the submit button. You will then be taken to the payment form (you can send payment with any major credit card by paypal.com, or by check through snail mail, look at order form for more info).
(2) Second, you will receive a conformation by email when we began work. At that time we may request additional information for your website.
(3) Last, after we have completed your website, you be will emailed a link to your site so that you may look it over and let us know of any corrections, adjustments, or improvements that should be made. After any corrections are made the site will be done and fully functional, but we will continue your eMarketing and making minor adjustments to get you placed high on the search engines for the next year.
total construction time: about 2 to 3 weeks, times may very due to nature of site.

Note:Remember we request for your payment after we have completely built your website and you are satisfied with it.
Note: We will request information/contents for website's pages after work on website has began,be ready to inform us.

Start Filling in Order Form Here:
Select Website Design:
Select design by clicking the circle BELOW the design, this will fill in the circle.

Design #1
Design # 1
Design #2
Design # 2
Design #3
Design # 3
Design #4
Design # 4

Design #5
Design # 5
Design #6
Design # 6
Design #7
Design # 7
Design #8
Design # 8

Design #9
Design # 9
Design #10
Design # 10
Design #11
Design # 11
Design #12
Design # 12

Design #13
Design # 13
Design #14
Design # 14
Design #15
Design # 15

Full Name:

Email Address:
Office Name:

Office Address:

State:

Zip Code:

Office Phone #:

Office Hours:

Pages you would like to see on your website:
We suggest the following pages; services, contact, about chiropractic, staff, and new patent info.
Contents of pages will be requested after work on website has began.

Website Address:

(ex: www.OfficeName.com)
NOTE: Some names may already be taken, click here to find out.

eFeatures:
Leave the eFeatures you want on your website checked.
eBasic forms
Insurance Form
Quadruple Visual Analogue Scale Form
Low Back Pain Disability Questionnaire
Examination Form
Intake and History
Neck Pain Disability Questionnaire
I have my own form(s) I would like on the website.
If you check the above box we can have your forms faxed to us and placed on your website.
We will email you our fax number or you can have it snail mailed to us.
eEdit
eStore
eCalander
eScheduler
eNewsletter
eMarketing

Special Notes to us:
Any extra information you would like to bring to our attention.

Type of Payment:
Credit Card
We accept all major credit cards (Visa, MasterCard, Discover, and American Express).
Payment is through Paypal.com the leader in secure Internet payments. Check
Checks can be written out to Sean Gallagher
And sent to the address:
289 Steiner Bridge Rd.
Valencia, Pa 16059

Number of Months you would like your website hosted for:
Months can be added at a later date and as needed for the same cost ($4 per month)

You agree you have read our disclaimer and that you will abide by it.
Check box for Yes

Note: We may request additional information from you to complete your order.
Note: We will request information/contents for pages after work on website has began,be ready to inform us.
Note: By submitting an order you are agreeing that you have read our disclaimer and you will act accordingly.