Alkem

{{ Form::open(['url' => '#', 'name' => 'validateForm', 'id' => 'validateForm', 'enctype' => 'multipart/form-data']) }}

HCP Central Code*

REGION*

RSM Central Code*

HCP Name*

HCP Mobile no*

HCP WHATS APP NO*

HCP Email ID*

Activation Date*

RSM NAME*

RSM EMP CODE*

RSM EMAIL*

RSM MOBILE*

ME FS CODE*

ME EMP CODE*

HQ NAME*

HQ CODE*

HCP GARNET CODE*

@if ($contractData->activity_type=='doctor') HCP PAN NO @else Institution's PAN Number @endif *

HCP REG. NO

SPECIALITY*

QUALIFICATION*

NO OF YEARS OF EXPERIENCE (after completion of highest qualification)

THERAPY

ADDRESS*

Place*

PINCODE*

STATE NAME*

@if ($contractData->activity_type=='doctor')HCP SAP VENDOR CODE @else INSTITUTION VENDOR CODE @endif*

HCP UNIQUE CODE*

Cost Center Code*

Order No*

REGION*

@if ($contractData->activity_type_id == 1)

Contract Amount*

Patient Count*

@endif