Order Form

Dental Patient Education - Arabic/English Languages

How to use this Form:
To start, please type 2534 in this box
to prove that a human and not a program is using 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:

Instructions: I would like to make the following changes on the web site: (optional) 
Changes are limited to replacement of one item at the web site   


  1. Web site was developed to include the client's name and title in Arabic language so that to trigger Google in listing it at Arabic Google. Also, the main clinic's web site heading and the content were provided in two languages.
  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) and under the clinic's heading.
  5. Client is provided with information for submitting the new web site to register it at Arabic / English Googles and Yahoo.

FeesSpecial fees are listed at 50% discount of regular fees.

  • Standard Web Site Design, Arabic/English languages - No Changes: $77
  • Custom - Requested Changes: $15 per change  + $77  = $
    • The request for item replacement is limited to one item.
    • Mistakes are corrected at no charge.
    • Word changes are permitted. However, every change will incur a fee.
      Number of Changes
      $15    + $77 = $
  •   Development of Arabic Language Web Site:  Fee $83   $   Sample 1, Sample 2
  • TOTAL ORDER: please add the fees for selected services and enter here $
  • BONUS: Deadline October 31, 2016

    Free life time listing at following DMS directories for clients who send their payments to reach DMS by above deadline:


  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. Tracking Number (None - US Clients) 
  5. 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 click on the method used to send your payment:
.USA Clients: 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

  Non-USA Clients:
To avoid delays in processing your order,
please complete/send this form on line and we will contact you for information about transferring your funds.)

>>> Please Review The completed Form before you click on "Send It in". <<<

E. Mail
: affluentpatients@gmail.com

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