You have chosen to sponsor your bid up to a maximum amount of .
Please remove X's for the URL: http://www.saXndXiegXospXinaXlcareX.com/SXDSXRTEST/form-questionnaire_print.php
When customer fills out the form online they have a choice to print it themselves or submit it to the people at the Mission valley office / Oceanside office. When the office receives the submitted form they need to be able to simply print it out and have it look exactly as the print out version. You might want to print the blank form to better understand what I am talking about. The submitted version and the printed version need to be identical. There needs to be 10 separated pages for the print out. The patients name and date should be at the top of each page and that's how you should see the page breaks. Once you fill out the patients name on page one, it should auto populate on the others.
Save the data to a text file so that they can load the same form as it is but populated with the data, and then they can print it out at the office as if they are printing the empty form.
Agreed price is $175 and should be completed 100% within 3 days.