Html5 Form Validation

Name

First Name *
Middle Name
Last Name *

AGE

DOB *

GENDER

Gender

ADDRESS:

House No. *
locality *
City *
Pincode *

MOBILE NO:

Phone No *
No spaces or brackets e.g. 9999999999 Your mobile number is valid
Alternate No.
No spaces or brackets e.g. 9999999999 Your mobile number is valid

EMAIL ID

Email *
Please enter a valid email address e.g. swapnil@example.com Your email address is now valid

SKYPE ID

Skype id

APPOINTMENT

Purpose of Appointment

DIAGNOSIS

Diagnosis (if known)

TIME SLOT

Preferred day

TIME SLOT

Preferred time slot

MODALITY

Preferred modality

REFERRAL SOURCE

Referral source