Initial Payment Form

Clinic Address

Payment

ItemQuantityPrice

Initial Monthly Ad Fee ($5000)

1

$5000.00

Initial Monthly Ad Fee ($2000)

1

$2000.00

Initial Monthly Ad Fee ($10,000)

1

$10000.00

Initial Monthly Ad Fee ($3000)

1

$3000.00

Initial Monthly Ad Fee ($4000)

1

$4000.00

Initial Monthly Ad Fee ($1500)

1

$1500.00

Initial Monthly Ad Fee ($2500)

1

$2500.00

Initial Monthly Retainer Fee

1

$1500.00

Initial Monthly Software Fee

1

$200.00

Order Summary

ItemQuantityAmount

Initial Monthly Ad Fee ($5000)1$ 5000.00

Order Total

$

* 100% Secure & Safe Payments *