LOS ANGELES AREA DENTISTS New Member Signup Area

Welcome! We look forward to being instrumental in promoting your DENTAL practice online. To begin your Membership please complete the form below. Upon verification of your credentials and/or Board certification(s) you will receive an E-mail response from LAD Member Services. Thank you for choosing INTERNET MEDICAL GROUPŽ.

GENERAL PRACTICE INFORMATION

Who is submitting this form:

Physician First Name

Physician Last Name

E-mail address

E-mail address reconfirm:

E-mail to which you wish us to send your patient referrals:

Practice Manager:

Patient Coordinator:

Practice Address:

Practice Address 2:

Practice Telephone:

Practice FAX:

Practice Web site Internet address:

Do you need a new practice Web site?

YES NO

Practice Specialty

Board certification Date:

Please tell us more about your practice. You may also list your societal memberships and affiliations here:

MEMBER SERVICES ORDER FORM

	SPECIAL LIMITED TIME OFFER! LIFETIME MEMBERSHIP/SIMPLE DENTAL PRACTICE LISTING ONLY $499.99 USD! Includes your simple practice listing on the LA-DOCTOR.COM Dentists & Dentistry directory for thousands of our viewers and subscribers to find.
	ENHANCED MEMBERSHIP PACKAGE/BOLD PRACTICE LISTING $299.99 USD per annum. This option includes your bold practice listing on the on the LA-DOCTOR.COM Dentists & Dentistry directory + a hyperlink to your practice Web site or your MEMBER WEB PAGE (see extras below).
	PRACTICE SUPER PACKAGE WITH WEBSITE $3,500 USD Includes: 1. COMPLIMENTARY PATIENT REFERRALS for one full year with SPECIAL ATTENTION (ie. we contact the patient for you and recommend that the patient visits you). 2. PRACTICE WEB SITE 5 page Web site which includes: Your CV, practice location and contact information, payment & billing information, description of procedures and up to 10 patient photos (before & afters) Additional Web pages cost $500 each. 3. BOLD PRACTICE LISTING on the applicable directory with a HYPERLINK to your practice Website. FREE HOSTING for the full year. *4. One PRACTICE BANNER AD* (see extras below). We build your PRACTICE BANNER AD and place it in up to three area locations or categories on the applicable Web site. 5. One PRESS RELEASE (see extras below) to 20,000 targeted subscriber emails. We suggest you use this service for product/book or practice Web site promotion.

ORDER PRACTICE PROMOTION EXTRAS
	MEMBER WEB PAGE $500 USD If you do not yet have a practice Web site Member Services can build a Web page for your practice and link it to your Member listing on the applicable directory. Your Member Web page will contain your practice address, contact information, C.V., procedures performed and patient payment options.
	BANNER ADVERTISING $1,000 USD per annum. Banner Advertising is one of the best ways to attract patients to your practice Web site. If you do not have a practice banner we will build one for you at no charge when ordering this service. Your practice can now target both potential patients and general consumers using our directory systems. Banner advertising has been proven to increase consumer recall and brand name recognition. Banner Ads are rotated upon page entry and are limited to only ten (10) Banners per page. Your banner may be linked to any URL (Internet address) including your practice Web site.
	MEDICAL PRESS RELEASES & TARGETED E-MAIL MARKETING Only $1,000 USD per mailing! Do you have a new medical procedure, book or product to promote? With access to over a quarter of a million Internet Medical Group Web site subscribers and thousands of medical writer, physician, clinic and hospital administrator E-Mail addresses, this option provides our Members the opportunity to reach a receptive target audience with their message directly via E-mail. Your message can include detailed information about your practice and it's services with a link to your Web site and/or URL of choice. You may use up to 10 lines and 360 characters in your text ad.

SERVICE AUTHORIZATION & MEMBERSHIP SIGNUP

To begin your Membership please check the agreement box below and then press the Membership activation button. Upon verification of credentials/Board certifications you will receive an E-mail response from Member Services and a FAX from Billing within 24 hours. Thank you for choosing INTERNET MEDICAL GROUPŽ.

PLEASE NOTE: Submit this form ONLY if you are ready to activate your Membership. Because all Member services are performed in advance, payments for all services ordered are due within 72 hours of this form submission. All submissions are final.

I agree to the Membership Terms & Conditions below. Please bill me for the amount(s) indicated above and activate my Membership immediately.



MEMBERSHIP TERMS & CONDITIONS: Internet Medical Group guarantees that all services requested and purchased will be performed and displayed on the applicable web site(s) for at least one full year as of one week from the date on Member invoice pending full payment of Membership fees. INTERNET MEDICAL GROUP assumes no liability for false or misleading claims made by its Members and reserves the right to correct and/or delete any information as deemed appropriate. Member authorizes INTERNET MEDICAL GROUP to use any artwork and/or photography from Member's Web-site(s) and/or any other informational material(s) to create Member's advert. Any and all web & art work created for Member physicians by INTERNET MEDICAL GROUP is the intellectual and business property of INTERNET MEDICAL GROUP and may not be used in, or on, any other commercial media or Web site without the prior consent and written approval of INTERNET MEDICAL GROUP. All parties understand that INTERNET MEDICAL GROUP is an informational Internet service and that its sites are created solely for the purpose of publishing Member advertisements and promotional materials. There are no guarantees real or implied regarding the effectiveness of our services. INTERNET MEDICAL GROUP is not an ISP and cannot be held liable for "down-time" or ISP system crashes due to errors or ISP problems over which INTERNET MEDICAL GROUP has no control. INTERNET MEDICAL GROUP will not be liable for any claims or damages resulting from any such ISP Internet system failures. Membership fees must be mailed within 48 hours of sign-up. Because our Internet work for your practice is performed in advance, clicking on the MEMBERSHIP ACTIVATION button above constitutes an irreversible, legal and binding agreement to all of the above terms, conditions and payment arrangements and authorizes INTERNET MEDICAL GROUP to begin implementing your Membership services.