Clinic/Hospital/Organization Name:

Address:

Country:

State:

City:

Pincode:

Mobile No:

WhatsApp No:

Email ID:

DOB:

DOA:

Spouse Name:

Spouse DOB:

Sub Total:

Coupon Discount:
Remove

Total Amount:

Transaction charges:

Total Payable Amount:(% transaction charges)

Note:

The transaction charges on the amount has been charged as Online Payment Gateway charges.

Terms & Conditions

• The details entered above has been checked before submitting.

• The contact details like email, mobile number may be used to send regular updates like payment remainders, event and updates, etc

• I promise to pay the renewals before the due date, else will bear the penalty decided by the society.