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Fresh Start Order Form

Use this secure form to order your fully-installed, customized Electrology Practice website.

We will use the information you provide to do the initial setup and customization of your site. Any of this information can be changed or added at any time, if you don't want to list it now. If you need help with this form or want to place your order by telephone, please feel free to call us at 330-527-4018 or to email us.

Site Information
The domain name is your website address. It cannot contain any spaces or special characters like slashes. Example: MyElectrolysisPractice.com

If you have not yet selected a theme for your website, you can do so here.

Your Practice Information
If Yes, we will use this information to set up your locations, modalities, etc. Otherwise, we will contact you for this information.

Contact Us Information

About Us Information

Rates/Policies Information

Links Information
Optional Extras

Please select any of the optional extra items or services below that you would like to have added to your site. We will contact you for any additional information, such as testimonials, services information, a description of your desired colors/layout, your business card, etc. that may be required to complete your request.

Hosting Options

These options affect how we set up your hosting package. All fees from these options are paid to the hosting company, not to Hammer Data Systems.

This locks in the introductory monthly rate for three years instead of only one year.
This keeps your contact information private and reduces spam.
Billing/Contact Information

Please enter information as it appears on your credit card billing statement.

Credit Card Information

Comments and Additional Information
Terms and Agreements

I understand that by submitting this order form, I agree to the following:

* I agree to the above terms

Note: Your credit card will not be charged by submitting this order. We will confirm your eligibility for your selected theme and contact you with regard to any optional extras you have selected before charging your credit card.

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These website packages have been authorized by the American Electrology Association and are available exclusively to AEA Members. Not a member? Join the American Electrology Association today!