Website design with a form filled and e-signed

Avg Bid (USD)
Project Budget (USD)
$1500 - $3000

Project Description:
I am looking for a web designer to convert a medical authorization form into a website to be made.
The form is an authorization linked between doctors and vendors.
The site will need doctors to login and create a login using their license number and npi number and be able to electronically sign the form.
The form will then be able to be pulled up and printed by a vendor that is assigned to that form.

Skills required:
Graphic Design, HTML, PHP, Website Design
About the employer:
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