New Customer
Basic Details
First Name *
Last Name *
Phone Num *
1
7
20
27
30
31
32
33
34
36
39
40
41
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
60
61
62
63
64
65
66
77
81
82
84
86
90
91
92
93
94
95
98
211
212
213
216
218
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
248
249
250
251
252
253
254
255
256
257
258
260
261
262
263
264
265
266
267
268
269
290
291
297
298
299
345
350
351
352
353
354
355
356
357
358
359
370
371
372
373
374
375
376
377
378
379
380
381
382
385
386
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
685
686
687
688
689
690
691
692
850
852
853
855
856
872
880
886
960
961
962
963
964
965
966
967
968
970
971
972
973
974
975
976
977
992
993
994
995
996
998
1242
1246
1264
1268
1284
1340
1441
1473
1649
1664
1670
1671
1684
1721
1758
1767
1784
1849
1868
1869
1876
1939
Whatsapp Num *
1
7
20
27
30
31
32
33
34
36
39
40
41
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
60
61
62
63
64
65
66
77
81
82
84
86
90
91
92
93
94
95
98
211
212
213
216
218
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
248
249
250
251
252
253
254
255
256
257
258
260
261
262
263
264
265
266
267
268
269
290
291
297
298
299
345
350
351
352
353
354
355
356
357
358
359
370
371
372
373
374
375
376
377
378
379
380
381
382
385
386
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
685
686
687
688
689
690
691
692
850
852
853
855
856
872
880
886
960
961
962
963
964
965
966
967
968
970
971
972
973
974
975
976
977
992
993
994
995
996
998
1242
1246
1264
1268
1284
1340
1441
1473
1649
1664
1670
1671
1684
1721
1758
1767
1784
1849
1868
1869
1876
1939
Personal Details (Optional)
Email
Birthday (Year optional)
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YY
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Anniversary (Year optional)
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YY
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Work Phone Num
1
7
20
27
30
31
32
33
34
36
39
40
41
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
60
61
62
63
64
65
66
77
81
82
84
86
90
91
92
93
94
95
98
211
212
213
216
218
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
248
249
250
251
252
253
254
255
256
257
258
260
261
262
263
264
265
266
267
268
269
290
291
297
298
299
345
350
351
352
353
354
355
356
357
358
359
370
371
372
373
374
375
376
377
378
379
380
381
382
385
386
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
685
686
687
688
689
690
691
692
850
852
853
855
856
872
880
886
960
961
962
963
964
965
966
967
968
970
971
972
973
974
975
976
977
992
993
994
995
996
998
1242
1246
1264
1268
1284
1340
1441
1473
1649
1664
1670
1671
1684
1721
1758
1767
1784
1849
1868
1869
1876
1939
Qatar ID
Customer Category
Address Line 1
Address Line 2
Address Line 3
City
Zipcode/Zone
State
Country
Åland Islands
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
São Tomé and Príncipe
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (Dutch part)
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US)
United States (US) Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (US)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Health Details
Do you have skin allergies?
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Yes
No
Do you have back problem?
--Select --
Yes
No
Blood Pressure
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Low
Normal
High
Other Details
How did you hear about us?
--Select --
Word of mouth
Referral
Program
SMS
Walk in
Social media
Other
Others
I hereby confirm that the above information to my knowledege is correct.
