$50 simple form design contest / 72 hours

Need a form designed on A6 landscape. This is for a clinic that offers various services, they want to print the form on a thick card paper and give it to customers to fill in.

Next to the Name, Surname, Mob, Email on the right side there should be a line of blank squares so people can write each letter/number in a square.

To the left of each service name there should be an empty square box so customers can tick what they are interested in.
Here is the website of the clinic: http://www.thirtydoverstreet.com
The form should be black on white

Please use the logo of the clinic, circle with the number 30 in it on the form, get it from the website, if it’s of low quality don’t worry as we will replace it when we get the original file

Try and spread the information nicely on the page (A6 landscape)


Here is the text for the form:

PLEASE COMPLETE IN BLOCK CAPITALS:
Name: [25 squares]
Surname: [25 squares]
Mob: [15 squares]
Email: [25 squares]


PLEASE TICK SERVICES OF INTEREST:
Botox
Laser Hair Removal
GP Service
Teeth Whitening
Travel Vaccinations
Body Shaping
Hair Transplant
Breast Enhancement

 

Entry Sent via PM

 

Thank you franzceen:
1) I asked for the form to be black on white i.e. black text on white background
2) Please remove the buildings, it should be a clean, modern looking design
3) The boxes should start at the same line on the left
4) I am still waiting for other designers to submit their designs. I am offering $50 for this very easy job because I want a good quality design and I am surprised that only one designer (you) has sent designs. There is still one more day left so I am hoping to receive more designs today or tomorrow.

 

here's my try...


sorry for the quality of the logo...

 

Entry submitted via PM.

 

josephine - not bad
Nitroactive Media - Very nice

Contest finishes tomorrow and I am hoping to get more designs, there is still time!

Thank you in advance to all the good designers out there that are working on the designs for me.

 

Feedback please

 

At the moment Nitroactive Media are No.1 but I was asked by a designer working on the form to extend the contest by 24 hours giving him a chance to finish the work. So I believe it would be fair to let that designer finish and then I can decide between Nitroactive Media and the new design that is being done now.

Thank you everybody!

 

OK everybody, please ignore my previous message, the contest is now over and the winner is:

Nitroactive Media

 

As requested, here is my entry.