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First name is Required Invalid Last Name [Only Letters are Acceptable]

Last name is Required Invalid Last Name [Only Letters are Acceptable]

Clinic Name is required Invalid Clinic Name, Not more that 50 characters

Address is Required Invalid Address. Should consist of letter & number, not more that 100 characters

State is Required

Phone is Required Invalid Phone, Phone number should begin with country code 60 and follow with are code & 6 - 8 numbers

Email Address is Required Invalid Email Address

 

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