Patient Medical Device Website (w/users)

I am wanting a quote to design a website to the following specifications. The website needs a homepage, product details page, contact us page, and a mymeddevice page. The website needs a fresh professional look to it. It will promote a piece of technology that can be used by patients. The website will need to have the ability for customers to signup (pay either a membership or one-time price - I am still deciding this. I would like the option of letting them enter a code (similar to a coupon code) which would give them free access. This code should reference a database of codes that I control) and input data into text boxes, radio buttons, etc... They will also need the ability to upload images. The idea is to have the data stored and then they can print to a PDF on the website and save to their computer/flash drive. I would like to get some estimates at this time (max of $125). Thank you.