Custom Referral Database

I need a web2.0, AJAX loaded referral status database created in PHP & MySQL. The database will have 10 fields. * REP - Static Dropdown * FACILITY - dropdown with a choice for "Add New..." and a one line text field will pop up * Location - Static Dropdown (6 choices) * DCOTOR - dropdown with a choice for "Add New..." and a one line text field will pop up * PATIENT NAME - Text Field * REFERRED DATE - Calendar popup * Available - Calendar popup + TBD + __ weeks * INSURANCE - Multi select with a choice for "Add New..." and a one line text field will pop up * REFERRAL - Click icon to add, select company name, select contact, add optional note. Store the history of which co, person and the attached note. When selected an email should be sent to the contact with the details & note. The timestamp of the email should be stored and displayed on rollover in this field. The company names & contact's name and email address should be editable. Show the first 10 characters of the Company with (...) and on rollover show the rest of the details. * NOTES - show first 10 characters, rest on rollover Each record should have a view all icon that pops up a page of all of the details in a print friendly format. Highlight color option Stared All unique CSS classes (no tables) As few page refreshes as possible Login protected Please provide samples of similar work. I will not be providing design as I want your fresh approach and you design recommendations. More similar projects if this goes well!