SImple updates to Website AMCD

need to update:

On the "Online agreement" [url removed, login to view]

add the items below the "telephone" "email" fields so that they can be filled in by potential members? it will also help us process orders quickly. We can leave the username and attachment section the way it is. We will enter data manually for our members.

1. Front end

Date of Birth:

Street Address:


Zip Code:

CA. Drivers Lic#:

Patient ID Number or Recommendation Number:

Recommendation Issue Date:

Recommendation Expiration Date:

Doctor's Name:

Doctor's License Number:

Doctor's Phone Number:

Doctor's Website:



-- what is the correct format for the field: "expires" we tried a few different ways to enter the dates but none seem to work.

-- The "verified" field and "active" fields do not work correctly.

When we click active yes it changes the

verified to NO, that is wrong.

-- "Expires" field needs to be set up for manual entry

-- What is the "bonus" field for?

Skills: HTML, PHP, Website Design

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About the Employer:
( 148 reviews ) Half Moon Bay, United States

Project ID: #1089681

Awarded to:


Hey sir, I would like to help you right now :) Looking forward hearing from you. Cedricve

$30 USD in 0 days
(17 Reviews)

2 freelancers are bidding on average $65 for this job


Let me fix this. Thanks

$100 USD in 2 days
(66 Reviews)