PLAN 10_INRPLAN 10_INR₹10.00PLAN 10_INRBECOME A MEMBER – FOR PEDIATRICIANS ONLYRegistration Form All fields marked with * are mandatory to enter* Surname * Do not enter prefix Dr.* Name * * GenderMaleFemale* Date of Birth * * Email Address * * Confirm Email Address * * Mobile Number (Username) * Do not enter prefix +91Allow only 10 digit* Password * Strength: Very WeakHospital Address Residential Address * StateGujaratGujarat * * City * * CIAP Number * * Pincode * * Profile PictureDone(Use Cropper to set image and <br/>use mouse scroller for zoom image.)Done(Use Cropper to set image and use mouse scroller for zoom image.)Drop file here or click to select.jpg, jpeg, png / Max 5 MB Select Your Payment GatewayRazorpayHow you want to pay?Auto Debit PaymentManual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Coupon Discount Amount : , Final Payable Amount: Submit
