Order Form

Use this page to order one of the MSEA options. Please fill out this order form and click on the blue button. You will then be taken to our secure shopping cart where you can complete your order. If you have any problems filling out the order form, please contact us here.

 Silver    Gold    Platinum   
Silver $795 - Gold $895 - Platinum $995
 Already Listed    Please Add Me    Not Interested   

(If you're already on Dr. Tom's Mercury Safe Directory you'll receive a $225 discount for the first year. If you're not listed on the Directory and would like to be added at this time, you'll also get a discounted price at checkout.)

(Enter the URL of your website's home page.)

(Please enter the email address of your web person or person who will add the link from your website to the new MSEA pages we created for you.)

(Please enter the name of your web person or person who will add the link from your website to the new MSEA pages we created for you.)

(Your first name as you wish it to appear on the Add-On pages.)

(The last name you as wish it to appear on the Add-On pages.)

(Enter the degree you wish to see appear after your name.)

(Enter an email address we can use to confirm your order. This email address will not be used for marketing and will not be placed on a mailing list.)

 Male    Female    Other   

(Gender is required in order for us to personalize your new Add-On pages.)

(Check this box if you are IAOMT SMART certified.)

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If you have any questions about ordering an Add-On click here to contact us.