@model HealthchoiceMVC.NonDbModels.RegisterPracticeViewModel @{ ViewBag.Title = "Healthchoice Registration"; }

@ViewBag.Title

@using (Html.BeginForm("RegisterPractice", "Account", FormMethod.Post, new { @class = "form-horizontal", role = "form" })) { @Html.AntiForgeryToken()

Register a new Practice


Next Steps?

You are about to register a practice with Healthchoice. In order to continue you will need to register an account with Healthchoice and complete some additional information relating to your practice. The account you register will be used to manage your practice, practitioners and patients.

You will receive an email from us to validate your email address. Once you have validated your email address, your practice will be activated.

Your details

@Html.ValidationSummary("", new { @class = "text-danger" })
@Html.LabelFor(m => m.TitleId, new { @class = "col-md-4 control-label required" })
@Html.DropDownListFor(m => m.TitleId, new SelectList(ViewBag.TitleList, "Value", "Text"), new { @class = "form-control" }) @Html.ValidationMessageFor(m => m.TitleId, "", new { @class = "text-danger" })
@Html.LabelFor(m => m.FirstName, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.FirstName, new { @class = "form-control" })
@Html.LabelFor(m => m.LastName, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.LastName, new { @class = "form-control" })
@Html.LabelFor(m => m.ContactNumber, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.ContactNumber, new { @class = "form-control" })
@Html.LabelFor(m => m.Email, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.Email, new { @class = "form-control" })
@Html.LabelFor(m => m.Gender, htmlAttributes: new { @class = "control-label col-md-4" })
@Html.DropDownListFor(m => m.Gender, new SelectList(ViewBag.GenderList, "Value", "Text"), new { @class = "form-control" })
@Html.LabelFor(m => m.IDTypeId, htmlAttributes: new { @class = "control-label col-md-4 required" })
@Html.DropDownListFor(m => m.IDTypeId, new SelectList(ViewBag.IdType, "Value", "Text"), new { @class = "form-control" })
@Html.LabelFor(m => m.IdentityNumber, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.IdentityNumber, new { @class = "form-control" })
@Html.LabelFor(m => m.Password, new { @class = "col-md-4 control-label required" })
@Html.PasswordFor(m => m.Password, new { @class = "form-control", rel = "tooltip", data_toggle = "tooltip", title = "Password must be more than 6 characters and contain a number, both upper and lowercase letters and a special character.", data_placement = "right", })
@Html.LabelFor(m => m.ConfirmPassword, new { @class = "col-md-4 control-label required" })
@Html.PasswordFor(m => m.ConfirmPassword, new { @class = "form-control" })

Practice Details

@Html.LabelFor(m => m.PracticeName, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.PracticeName, new { @class = "form-control" })
@Html.LabelFor(m => m.PracticeTradingName, new { @class = "col-md-4 control-label" })
@Html.TextBoxFor(m => m.PracticeTradingName, new { @class = "form-control" })
@Html.LabelFor(m => m.PracticeNumber, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.PracticeNumber, new { @class = "form-control", rel = "tooltip", data_toggle = "tooltip", title = "Practice Number is the last 7 digits of your practice number.", data_placement = "right", }) @Html.ValidationMessageFor(m => m.PracticeNumber, "", new { @class = "text-danger" })
@Html.LabelFor(m => m.AffiliationNumber, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.AffiliationNumber, new { @class = "form-control", rel = "tooltip", data_toggle = "tooltip", title = "SASP number is the full SASP number without spaces.", data_placement = "right", }) @Html.ValidationMessageFor(m => m.PracticeNumber, "", new { @class = "text-danger" })
@Html.LabelFor(m => m.VatNumber, new { @class = "col-md-4 control-label" })
@Html.TextBoxFor(m => m.VatNumber, new { @class = "form-control" })
@Html.LabelFor(m => m.RegistrationNumber, new { @class = "col-md-4 control-label" })
@Html.TextBoxFor(m => m.RegistrationNumber, new { @class = "form-control" })
@Html.LabelFor(m => m.PracticePrimaryContactNumber, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.PracticePrimaryContactNumber, new { @class = "form-control" })
@Html.LabelFor(m => m.PracticePrimaryContactEmail, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.PracticePrimaryContactEmail, new { @class = "form-control" })
@Html.LabelFor(m => m.AddressLineOne, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.AddressLineOne, new { @class = "form-control" })
@Html.LabelFor(m => m.AddressLineTwo, new { @class = "col-md-4 control-label" })
@Html.TextBoxFor(m => m.AddressLineTwo, new { @class = "form-control" })
@Html.LabelFor(m => m.AreaSuburb, new { @class = "col-md-4 control-label" })
@Html.TextBoxFor(m => m.AreaSuburb, new { @class = "form-control" })
@Html.LabelFor(m => m.CityTown, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.CityTown, new { @class = "form-control" })
@Html.LabelFor(m => m.PostalCode, new { @class = "col-md-4 control-label required" })
@Html.TextBoxFor(m => m.PostalCode, new { @class = "form-control" })
@Html.LabelFor(m => m.NetworkAffiliationId, new { @class = "col-md-4 control-label required" })
@Html.DropDownListFor(m => m.NetworkAffiliationId, new SelectList(ViewBag.NetworkAffiliationList, "Value", "Text"), new { @class = "form-control" })
@*@Html.LabelFor(m => m.TermsAndConditions, new { @class = "col-md-4 control-label" })*@ @*@Html.LabelFor(m => m.TermsAndConditions, new { @class = "col-md-4 control-label" })*@
@Html.CheckBoxFor(m => m.TermsAndConditions, new { @class = "form-control" }) @*@Html.ValidationMessageFor(m => m.TermsAndConditions)*@
} @section Scripts { @Scripts.Render("~/bundles/jqueryval") }