Order Form
For Specialists Who Like To Provide Services To Arab Cash Patients

How to use this Form:

Use one Form per Order.
Type in the Form, on screen response, (fill out all applicable blanks. For others , please type "NA" not applicable)
If you make a mistake, backspace and type again, or highlight the entire box and hit "Backspace".
Press "TAB" to move between blank spaces.

I would like to order the following group of services and products :

  1. Services: Design of  an Arabic web site to describe my skills and my procedures. Also, I would like to receive a free website hosting value $83 per year):  Sample 1     Sample 2      Sample 3

  2. I would like my name recommended for the list "Guest Speakers For Future Arab Conferences"

  3. List my clinic at the following Arab web sites

Fees :
Above group of services: 
$195 (one time fee)  Samples


  • Made in full and in advance, checks, no credit cards.
  • Check Number  
  • Payment Date   

Contact Information:
First Name   Middle Initials   Family Name
Business Name
Address   City   
Country Info 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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