{"id":843,"date":"2023-07-25T05:37:38","date_gmt":"2023-07-25T05:37:38","guid":{"rendered":"https:\/\/magpinshospital.in\/?page_id=843"},"modified":"2023-07-26T12:48:48","modified_gmt":"2023-07-26T12:48:48","slug":"registration-form","status":"publish","type":"page","link":"https:\/\/magpinshospital.in\/index.php\/registration-form\/","title":{"rendered":"registration form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"843\" class=\"elementor elementor-843\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4ef9897 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4ef9897\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-809341f\" data-id=\"809341f\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5e6e0ea elementor-widget elementor-widget-heading\" data-id=\"5e6e0ea\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.14.0 - 26-06-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h3 class=\"elementor-heading-title elementor-size-default\">Please fill up the form to book an appointment<\/h3>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-73c85f4 elementor-widget elementor-widget-shortcode\" data-id=\"73c85f4\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f857-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/843#wpcf7-f857-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"857\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.7\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f857-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:857,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;MEDICINE&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;PAEDIATRIC&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;SURGEON&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;PAEDIATRICS SURGEON&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;DIABETOLOGIST&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ENT&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;PULMONOLOGIST&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;PSYCHIATRIST&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;INTENSIVIST&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;DERMATOLOGIST&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;NEUROLOGY&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;NEPHROLOGIST&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;CARDIOLOGY&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;ORTHO&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;CTVS&quot;}]},{&quot;then_field&quot;:&quot;-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;docfield&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;NEUROSURGEON&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:true}}\" \/>\n<\/div>\n<p><label> Patient's Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-pname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"pname\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-pname\" \/><\/span> <\/label>\n<\/p>\n<p><label> Email:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> DOB:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span><\/label>\n<\/p>\n<p><label> Select Gender:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gender\" value=\"Male\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gender\" value=\"Others\" \/><span class=\"wpcf7-list-item-label\">Others<\/span><\/label><\/span><\/span><\/span> <\/label>\n<\/p>\n<p><label> Contact Number:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"con1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"con1\" \/><\/span> <\/label>\n<\/p>\n<p><label> Alternate Number: (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"altnum1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"altnum1\" \/><\/span> <\/label>\n<\/p>\n<p><label> Permanent Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"paddress\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"paddress\" \/><\/span><\/label>\n<\/p>\n<p><label> Village:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"village1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"village1\" \/><\/span><\/label>\n<\/p>\n<p><label> P.O:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"po1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"po1\" \/><\/span><\/label>\n<\/p>\n<p><label> District:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dist1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dist1\" \/><\/span><\/label>\n<\/p>\n<p><label> State:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state1\" \/><\/span><\/label>\n<\/p>\n<p><label> PIN:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pin1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pin1\" \/><\/span><\/label>\n<\/p>\n<p><label> Residential Address: (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"raddress\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"raddress\" \/><\/span><\/label>\n<\/p>\n<p><label> Village: (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"village2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"village2\" \/><\/span><\/label>\n<\/p>\n<p><label> District: (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dist2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dist2\" \/><\/span><\/label>\n<\/p>\n<p><label> PIN: (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pin2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pin2\" \/><\/span><\/label>\n<\/p>\n<p><label> Select Doctor<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"docfield\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"docfield\"><option value=\"DR. GIRINDRA NATH GOGOI (MEDICINE)\">DR. GIRINDRA NATH GOGOI (MEDICINE)<\/option><option value=\"DR. NITIN BHARTIA (MEDICINE)\">DR. NITIN BHARTIA (MEDICINE)<\/option><option value=\"DR. APURBA DUTTA (MEDICINE)\">DR. APURBA DUTTA (MEDICINE)<\/option><option value=\"DR. SUMI BARUAH (PAEDIATRIC)\">DR. SUMI BARUAH (PAEDIATRIC)<\/option><option value=\"DR. RAZVI DAS (SURGEON)\">DR. RAZVI DAS (SURGEON)<\/option><option value=\"DR. MANOJ GOGOI (PAEDIATRICS SURGEON)\">DR. MANOJ GOGOI (PAEDIATRICS SURGEON)<\/option><option value=\"DR. MANAS GOGOI (DIABETOLOGIST)\">DR. MANAS GOGOI (DIABETOLOGIST)<\/option><option value=\"DR. NASIM AHMED SAIKA (ENT)\">DR. NASIM AHMED SAIKA (ENT)<\/option><option value=\"DR. MRIGANKA MADHAV MISHRA (PULMONOLOGIST)\">DR. MRIGANKA MADHAV MISHRA (PULMONOLOGIST)<\/option><option value=\"DR. TRIBENI BHUYAN (PSYCHIATRIST)\">DR. TRIBENI BHUYAN (PSYCHIATRIST)<\/option><option value=\"DR. IRINE BEYPI (INTENSIVIST)\">DR. IRINE BEYPI (INTENSIVIST)<\/option><option value=\"DR. PRERNA AGARWAL (DERMATOLOGIST)\">DR. PRERNA AGARWAL (DERMATOLOGIST)<\/option><option value=\"DR. RUPAM HAZARIKA (NEUROLOGY)\">DR. RUPAM HAZARIKA (NEUROLOGY)<\/option><option value=\"DR. SAWJIB BORPHUKAN (NEPHROLOGIST)\">DR. SAWJIB BORPHUKAN (NEPHROLOGIST)<\/option><option value=\"DR. DARPAN GOGOI (CARDIOLOGY)\">DR. DARPAN GOGOI (CARDIOLOGY)<\/option><option value=\"DR. KRISHNA N.D. BARUAH (CARDIOLOGY)\">DR. KRISHNA N.D. BARUAH (CARDIOLOGY)<\/option><option value=\"DR. PANKAJ JYOTI SONOWAL (ORTHO)\">DR. PANKAJ JYOTI SONOWAL (ORTHO)<\/option><option value=\"DR. ZAHIR PARWES ISLAM (ORTHO)\">DR. ZAHIR PARWES ISLAM (ORTHO)<\/option><option value=\"DR. DIPAK CHOUDHARY (CTVS)\">DR. DIPAK CHOUDHARY (CTVS)<\/option><option value=\"DR. DHURBO JYOTI KURMI (NEUROSURGEON)\">DR. DHURBO JYOTI KURMI (NEUROSURGEON)<\/option><\/select><\/span> <\/label>\n<\/p>\n<p><label> Your message (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-message\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control has-spinner wpcf7-submit\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Please fill up the form to book an appointment<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":""},"_links":{"self":[{"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/pages\/843"}],"collection":[{"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/comments?post=843"}],"version-history":[{"count":16,"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/pages\/843\/revisions"}],"predecessor-version":[{"id":863,"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/pages\/843\/revisions\/863"}],"wp:attachment":[{"href":"https:\/\/magpinshospital.in\/index.php\/wp-json\/wp\/v2\/media?parent=843"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}