Design for an website

I need web-design for a single page on PSD format. We want a single page website similar to [login to view URL] The website will provide discount coupons for people related to medical/ dental services. So use related images. We will leave them on you. The website url will be ... so please use this in standard header and footer information. The website must have the following - 1. a form with the fields - First Name, Last Name, Email, Phone, a chekcbox (Yes, I’d like my coupon sent to my mailing address.) and a print button 2. a place for a video/audio/flash content same as the above mentioned website. 3. an image describing the 3 easy steps for saving a coupon - #1print, #2 take to your pharmacy with your prescription,#3 save! 4. a short description in an appropriate place - " Welcome to hydrocodone [login to view URL] , the next step is to click print on the button below to receive your coupon. The coupon can be redeemed at over 62,000 pharmacies Nationwide. Simply give the coupon to your Pharmacist with your Doctors prescription and we guarantee the lowest possible price. If you are a provider and would like to offer coupons to your patients please email us your address, contact name and the quantity of coupons you desire and we will mail them to you the next business day." [login to view URL] website will have the same color scheme as the attached pdf. We are welcome to any suggestion and queries. So, if anything comes up in your mind, feel free to ask us.