Create Account
Register to book appointments online
{!! Form::open([
'route' => 'front.patient.register',
'method' => 'POST',
'class' => 'auth-ajax-form',
]) !!}
{!! Form::text('first_name', null, [
'class' => 'form-control',
'placeholder' => 'First Name',
'autocomplete' => 'off',
'minlength' => '3',
'maxlength' => '50',
'oninput' => "this.value = this.value.replace(/[^a-zA-Z\s]/g, '')"
]) !!}
{!! Form::label('first_name', 'First Name') !!}
{!! Form::text('last_name', null, ['class' => 'form-control', 'placeholder' => 'Last Name','autocomplete' => 'off', 'minlength' => '3',
'maxlength' => '50','oninput' => "this.value = this.value.replace(/[^a-zA-Z\s]/g, '')"]) !!}
{!! Form::label('last_name', 'Last Name') !!}
{!! Form::text('country_code', null, [
'class' => 'form-control',
'id' => 'header_country_code',
'placeholder' => '+91',
'autocomplete' => 'off'
]) !!}
{!! Form::text('phone_number', null, [
'class' => 'form-control',
'placeholder' => 'Mobile Number',
'autocomplete' => 'off',
'maxlength' => '10',
'inputmode' => 'numeric',
'oninput' => "this.value = this.value.replace(/[^0-9]/g, '').slice(0, 10)"
]) !!}
{!! Form::label('phone_number', 'Mobile Number') !!}
{!! Form::email('email', null, ['class' => 'form-control', 'placeholder' => 'Email','autocomplete' => 'off']) !!}
{!! Form::label('email', 'Email Address') !!}
{!! Form::password('password', ['class' => 'form-control', 'placeholder' => 'Password']) !!}
{!! Form::label('password', 'Password') !!}
{!! Form::hidden('dial_code', null, ['id' => 'patient_dial_code']) !!}
{!! Form::hidden('dial_iso', null, ['id' => 'patient_dial_code_iso']) !!}
{!! Form::close() !!}
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 }}){kind=logo}