Patient Registration

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Business or Client Name is required
Contact Name is required
Invalid Email, proper format "name@something.com" Email is required
Phone is required
Date of Birth (mm/dd/yyyy) is required
Street is required
Suburb is required
State is required
Postcode is required

Username is required
Password is required
Confirm Password is required
>> HINT: The password should be at least seven characters long. To make it stronger, use upper and lower case letters, numbers and symbols like ! " ? $ % ^ & ).
 
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