Order Form

Dental Patient Education - Arabic/English Languages

How to use this Form:
Use one Form per order.
Type in the Form, on screen response, (complete applicable blanks). 
Press "TAB" to move between blank spaces. 
DO NOT CLICK ON "ENTER" while completing the form. If you do that, you will close the form and send incomplete Form!
DO NOT press the  "BACK" button because all information will be deleted if you leave this web page.

I would like to order for my practice the website " Dental Patients Frequently Asked Questions" Arabic/English Languages: Sample

Instructions: I would like to make the following changes on the web site: (optional)    


  1. Web site is developed to include the client's web site heading and the content provided in two languages, same as the Sample.
  2. The client's web site heading is linked to the client's main web site. Also, the "CONTACT" is included under the heading.
  3. Place the client's web site heading at the top of the Arabic/English web site.
  4. Client's name is shown at the web site address (URL) sample  http://www.drgoodmanfaq.dmsindex.com/
  5. Client is provided with information for submitting the new web site to register it at Google and Yahoo.

Fees : 
Special fees are listed at
50% of regular fees.

  • Standard - No Changes: $95
  • Custom - Requested Changes: $15 per change
    Number of Changes
    $15 = $


  1. USA Dollars, Checks only, no credit cards.
  2. Orders are Paid in full and in advance by checks .
  3. Check Number (US Clients) 
  4. Payment Date 

Client  Information:
First Name   Middle Name   Family Name
Business Name
Address   City    State/Zip Code 
E-mail Address   
Web Site Address

Sending The Order Form .

Please complete the form on line, then print and mail it with your check to:
Doctors' Marketing Service
P.O. Box 748 , Lake Forest, California 92609-0748

E. Mail: affluentpatients@gmail.com

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