iCareUpdates - Request for site setup for Family or Close Friend

I hereby agree that this site may be set up by iCareUpdates subject to the Terms & Conditions of Use

1 Patient Surname

1 Patient First Name

Relationship to Patient

Estimated Time
Site Required

Reason for Site

9 Administration Password for Progress Reports

11 Administration Password for Guestbook

3 Picture Upload (we may alter picture to maximum of 256Kb to speed download)

Counter Style 01

Counter Style 03

Counter Style 00

Counter Style 02

Counter Style 04

Counter Style 05

Counter Style 07

Counter Style 06

Counter Style 08

6 Hospital Link (if required, this will be checked validity)

5 Please Choose Counter Style to Keep a record of the Number of Visitors to your site

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2 Top Main Page

Your Surname

Your First Name

Zipcode/Postcode

Country

Email Address

7 Centre Extra Details (if required)

10 Guestbook Label
to Guests

8 Progress Report Label

4 Side Main Page

Data to be Inserted on Web Site eg: ..1

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Data to be Inserted on Web Site eg: ..8

Extra Information or Questions (this will NOT be used on the web site set up unless specifically required)

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Do you want an Email sent to the above address when a message is left in the Guestbook

No Email Sent

Yes

Please list other email addresses for notification

If Other,
please Specify Reason

Please Tell Us how you found out about this Free Site

(Please make sure the file name is lower case eg: .jpg and NOT .JPG)