Order Form
Company Details
Company Name
       
Shipping address  
Street Address :
   
City :
State Zip
       
Billing Address  
Street Address :
   
City :
State Zip
Other :
   
       
Doctor Information
Please fill in the following
First Name :
   
Last Name :
    
Accreditations :
   
Office Phone Number :
   
E-Mail Address :
   
Website Name :
   
Other
       
Order Information
Product Selection: Please click on the product you would like to order:
New Patient Booster : Print Advertisements :
New Mover Developer : Brochures :
Relationship Builder : Recall Cards :
Referral Reminder Thank You Cards
Open House Invitations    
Birthday Cards Holiday Cards
       
Pictures and Logos
Pictures Logos and Stuff: Please browse and attach the following if you would like your card customized or you can also mail the information to sales@expressdm.com:
Logos :
 
Picture of Doctor :
 
Group Photo of Doctor and Staff :
 
Exteior Office Photo :
 
Maps to your office :
 
       
Special Instructions
Please note these instructions as you design the front and the back of my product. Thes instructions apply to the following: Please check below:
Personalized Direct Marketing:
Marketing Complements
New Patient Booster :
Print Advertisements :
New Mover Developer :
Practice Brochures :
Relationship Builders :
Recall Cards :
Referral Reminder
Thank You Cards
Birthday Cards
Holiday Cards
 
Custom
   
 
Front of Card
These instructions will notify designer of changes you require. Please be as specific as you can be so we can meet your needs
       
Back of Card, Inside Brochure
Please use this space to notify designer of elements you would like incorporated in your card. If you like a predesigned postcard back, please let us know product number. Please be as specific as you can be so we can meet your needs
       
List Selection Criteria
For our patient booster program, our normal selection criteria are as follows (5 mile radius of Doctors Office, Household income > $40k and families with kids ages 6-17). For our New Mover Developer Program, our criteria is as follows (Families that have just moved in within a 5 mile radius of the doctors location)
           
For "Relationship Reminder, Referral Reminder, Birthday Cards or Holiday Cards please browse and attach your patient file (.csv or excel format required)
Browse and Attach file:
 
 
Custom Products
Please use this space to notify designer of elements you would like incorporated in your custom product. Please be as specific as you can be so we can meet your needs.
       
Credit Card Information
Enter your credit card number and expiration date.
 
Credit Card #:
 
Credit Card Type :
   
Expiration Date: Month
Year (Two digit year: 1997~2020)