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.Surname can not be left blank.Please enter valid data.Please enter valid data.This Surname is invalid. Please enter a valid first name.*NameName can not be left blank.Please enter valid data.Please enter valid data.This name is invalid. Please enter a valid last name.*GenderMaleFemalePlease select one.Please enter valid data.*Date of BirthPlease select date.Invalid Date.*Email AddressEmail Address can not be left blank.Please enter valid email address.Please enter valid email address.This email is already registered, please choose another one.*Confirm Email AddressConfirm Email Address can not be left blank.Please enter email address again.Please enter email address again. Please enter email address again.*Mobile Number (Username) * Do not enter prefix +91Mobile Number (Username) can not be left blank.Please enter valid data.Please enter at least 10 characters.Maximum 10 characters allowed.This username is already registered, please choose another one.This Mobile Number (Username) is invalid. Please enter a valid username.Allow only 10 digit*PasswordPassword can not be left blank.Please enter valid data.Please enter at least 6 characters.Strength: Very WeakHospital AddressThis Field can not be left blank.Please enter valid data.Residential AddressThis Field can not be left blank.Please enter valid data.*StateStateGujaratPlease select atleast one option.Please enter valid data.*CityCity can not be left blank.Please enter valid data.Please enter valid data.*CIAP NumberCIAP Number can not be left blank.Please enter valid data.*PincodePincode can not be left blank.Please enter valid data.Please enter at least 6 characters.Maximum 6 characters allowed.Please enter valid data.*Profile Picture * Drop file here or click to select.Drop file here or click to select.Please select file.jpg, jpeg, png / Max 5 MBjpg, jpeg, png / Max 5 MBjpg, jpeg, png / Max 5 MBDone(Use Cropper to set image and use mouse scroller for zoom image.) Select Your Payment GatewayRazorpayHow you want to pay? Auto Debit Payment Manual PaymentPayment SummaryYour currently selected plan : , Plan Amount : Coupon Discount Amount : , Final Payable Amount: Submit