Registration Form
GLOBIRA MEDICAL SERVICES PVT. LTD.
*
mandatory fields
Member Name
*
:
Enter Name
Alphabets and space only.
Mobile No.
*
:
Enter Mobile No.
Only Number Allowed.
Email Id :
Enter Valid Email Id
Membership
*
:
--Select Membership--
5999 INR Individual Membership
14999 INR Family Membership
4999 INR Student Membership
3499 INR Student Membership
7999 INR Family Membership
3999 INR Individual Membership
3999 INR Individual Membership
7999 INR Family Membership
7999 INR Diabetes Membership
11999 INR Diabetes Membership
Location
*
:
--Select Location--
Kota, Rajasthan
Delhi/NCR
Select Location
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