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Patient
Title
*
-- Select --
Mr.
Mrs.
Ms.
Miss.
BABY.
B/O(F).
B/O(M).
MASTER.
BRIG.
CAPTAIN.
COL.
DR.(Mr).
Dr.(Mrs).
DR.(Ms.)
GEN.
GIANI.
LT.COL.
MAJOR.
RANI.
WG.COM.
Sample No.
Other
Gender
*
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M
F
UserName
*
First Name
*
Middle Name
Last Name
*
Email
*
Date of birth
*
Age
Age Title
Years
Months
Days
Mobile
*
(Should be 10 digit)
Phone
Password
*
Confirm Password
*
Address
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