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812-500-8585
NRI 360 Enrollment
Patient Name
(Required)
Gender
Gender
Male
Female
Others
Age
Phone
Email
(Required)
Address
Landmark
City
Pincode
Date Of Birth
(Required)
MM slash DD slash YYYY
Anniversary Date
MM slash DD slash YYYY
Sponsor/Caretaker Details
Sponsor name
Relationship
Sponsor Mobile Number
Sponsor Email
Sponsor City
Country
Plan Details
Select Plan
Select Plan
Silver
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Platinum
Plan Type
Plan Type
Single
Couple
Duration
Quarterly
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Annual
Name
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