CINXE.COM

Digital Healthcare Solution Library

<!DOCTYPE html> <html lang="en"> <head> <meta charset="utf-8" /> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <meta name="format-detection" content="telephone=no"> <meta name="theme-color" content="#1B367B"> <title>Digital Healthcare Solution Library</title> <meta name="description" content="Digital Healthcare Solution Library"> <meta name="keywords" content="Digital Healthcare Solution Library"> <link rel="preconnect" href="https://fonts.googleapis.com"> <link rel="preconnect" href="https://fonts.gstatic.com" crossorigin> <link href="https://fonts.googleapis.com/css2?family=Roboto:ital,wght@0,300;0,400;0,500;0,700;0,900;1,300;1,500&display=swap" rel="stylesheet"> <Link href="/src/dhsl-form/assets/css/bootstrap.min.css" rel="stylesheet"> <link href="/src/dhsl-form/assets/css/app.css" rel="stylesheet" /> <link href="/src/css/ds-main.css" rel="stylesheet" /> <script src="/src/js/jquery.min.3.6.0.js"></script> <link href="/src/css/jquery.fancybox.min.css" rel="stylesheet" /> <script src="/src/js/jquery.fancybox.pack.js"></script> <script src="/Areas/webadmin/assets/js/jquery.validate.min.js"></script> <script src="/Areas/webadmin/assets/js/jquery.validate.unobtrusive.js"></script> <script src="/Areas/webadmin/Scripts/js_functions/PageRelatedFunction.js"></script> <link href="/src/css/multiselect.css" rel="stylesheet" /> <style> .error { color: #d70d13; } </style> </head> <body class="p-0"> <div class="container text-center py-3 d-flex justify-content-center align-items-center"> <img src="/src/images/logo-tmc.png" class="img-fluid me-md-5 me-3" alt="Tata Memorial Center" title="Tata Memorial Center" /> <a href="https://www.ncgindia.org/" target="_blank"><img src="/src/images/logo.png" class="img-fluid" alt="NCG India" title="NCG India" style="max-width:200px" /></a> </div> <div class="container px-xl-5 px-lg-4 p-md-0"> <div class="row"> <div class="col-xl-8 col-lg-10 mx-auto"> <img src="/src/images/pic-dhsl-application.jpg" alt="Vendor Pre-Registration Form for Digital Health Solution Library" title="Vendor Pre-Registration Form for Digital Health Solution Library" class="img-fluid w-100" /> <header class="bg-primary text-center p-2"> <h4 class="m-0 text-white">Vendor Pre-Registration Form for <br />Digital Health Solution Library</h4> </header> </div> </div> <div class="row mt-3"> <div class="col-xl-8 col-lg-10 mx-auto"> <div class="card rounded-0"> <div class="card-body rounded-0 position-relative overflow-hidden"> <p>Please fill in the form below to confirm your interest. <span class="text-danger">*</span> marked fields are mandatory.</p> <hr /> <form action="/digitalhealthsolutionlibrary/dhslapplication" class="needs-validation" enctype="multipart/form-data" id="form" method="post" novalidate=""><input name="__RequestVerificationToken" type="hidden" value="oTqydaSC5HQF3gWaXZgzwibGMDU_SOzy1gICbh5gPwZAcOWDgEBFngDSa_k6SR8em5wRW57UC6CGnCed2hmtWldZn8OreKGCPwNgq3Mwzcs1" /> <div id="DHSL_Application_Form"> <!-- General Information --> <section> <div> <div class="row g-3 mb-5"> <div class="col-12 col-md-12"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_name">Company Name</label> <span class="text-danger">*</span> <input class="form-control shadow-none rounded-0" data-val="true" data-val-required="Please enter company name" id="company_name" name="company_name" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_name" data-valmsg-replace="true"></span> </div> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_website">Website</label> <span class="text-danger">*</span> <small class="text-muted"><i>(ex. https://www.domainname.com)</i></small> <input class="form-control shadow-none rounded-0" data-val="true" data-val-regex="Enter a valid URL" data-val-regex-pattern="http(s)?://([\w-]+\.)+[\w-]+(/[\w- ./?%&amp;=]*)?" id="company_website" maxlength="250" name="company_website" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_website" data-valmsg-replace="true"></span> </div> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_estd_year">Year of Establishment</label> <span class="text-danger">*</span> <input class="form-control shadow-none rounded-0" data-val="true" data-val-required="Please enter year of establishment" id="company_estd_year" maxlength="4" minlength="4" name="company_estd_year" oninput="this.value = this.value.replace(/\D+/g, &#39;&#39;)" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_estd_year" data-valmsg-replace="true"></span> </div> </div> <div class="col-12"> <label class="form-label fw-medium">Product Category <span class="text-danger">*</span></label> <div class="container"> <div class="row row-cols-1 row-cols-md-2"> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="A4BF9590-7E4C-440F-8DB7-EE211779B387" name="multi_category_id" value="A4BF9590-7E4C-440F-8DB7-EE211779B387" required> <label class="form-check-label" for="A4BF9590-7E4C-440F-8DB7-EE211779B387"> Preventive Care </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="2499E83E-2639-437E-B05D-1AC741AF4BBE" name="multi_category_id" value="2499E83E-2639-437E-B05D-1AC741AF4BBE" required> <label class="form-check-label" for="2499E83E-2639-437E-B05D-1AC741AF4BBE"> Outpatient Care </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="45C031CA-99B9-4029-95D9-683ABDEBE6D9" name="multi_category_id" value="45C031CA-99B9-4029-95D9-683ABDEBE6D9" required> <label class="form-check-label" for="45C031CA-99B9-4029-95D9-683ABDEBE6D9"> Inpatient Care </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="6B9E1AC0-A1DD-4014-B556-97CEAC1B9840" name="multi_category_id" value="6B9E1AC0-A1DD-4014-B556-97CEAC1B9840" required> <label class="form-check-label" for="6B9E1AC0-A1DD-4014-B556-97CEAC1B9840"> Rehabilitation, Palliative Care and Survivorship Care </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="14BC81CF-BC85-461C-AB06-D585AC31E11C" name="multi_category_id" value="14BC81CF-BC85-461C-AB06-D585AC31E11C" required> <label class="form-check-label" for="14BC81CF-BC85-461C-AB06-D585AC31E11C"> Imaging </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="0F7D3054-8B88-4FCA-9ACA-3906076FAF3C" name="multi_category_id" value="0F7D3054-8B88-4FCA-9ACA-3906076FAF3C" required> <label class="form-check-label" for="0F7D3054-8B88-4FCA-9ACA-3906076FAF3C"> Diagnostics </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="CC810CBD-D32B-424C-B964-8A583E8A04BF" name="multi_category_id" value="CC810CBD-D32B-424C-B964-8A583E8A04BF" required> <label class="form-check-label" for="CC810CBD-D32B-424C-B964-8A583E8A04BF"> Care Navigation / Care Coordination </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="F084FBAE-CF0B-4673-9A13-15765A601D50" name="multi_category_id" value="F084FBAE-CF0B-4673-9A13-15765A601D50" required> <label class="form-check-label" for="F084FBAE-CF0B-4673-9A13-15765A601D50"> Data Management &amp; Analytics </label> </div> <div class="form-check col"> <input class="form-check-input shadow-none multi_category_id" type="checkbox" id="DF7DD8AF-0F9B-4DC3-B011-3916E3D390CF" name="multi_category_id" value="DF7DD8AF-0F9B-4DC3-B011-3916E3D390CF" required> <label class="form-check-label" for="DF7DD8AF-0F9B-4DC3-B011-3916E3D390CF"> Others </label> </div> </div> </div> <span class="error" id="err_multi_category_id"></span> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_employee_count">Organization Size</label> <span class="text-danger">*</span> <select class="form-select shadow-none rounded-0 form-select dropdown-toggle" data-val="true" data-val-required="Please select organization size" id="company_employee_count" name="company_employee_count" required=""> <option value="">Select Organization Size</option> <option value="Small (1-20 employees)">Small (1-20 employees)</option> <option value="Medium (21-100 employees)">Medium (21-100 employees)</option> <option value="Large (101+ employees)">Large (101+ employees)</option> </select> <span class="field-validation-valid error" data-valmsg-for="company_employee_count" data-valmsg-replace="true"></span> </div> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_annual_organization_turnover">Annual Organization Turnover</label> <select class="form-control shadow-none rounded-0 form-select dropdown-toggle" id="company_annual_organization_turnover" name="company_annual_organization_turnover"> <option value="">Select Annual Organization Turnover</option> <option value="Upto 1 Cr.">Upto 1 Cr.</option> <option value="1-5 Cr.">1-5 Cr.</option> <option value="Above 5 Cr.">Above 5 Cr.</option> </select> </div> </div> </div> <!--Primary & Secondary Contacts--> <b class="text-uppercase">Contact Person</b> <hr /> <div class="row g-3 mb-4"> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_contact_person_1">Name <span class="text-danger">*</span></label> <input class="form-control shadow-none rounded-0" data-val="true" data-val-required="Please enter primary contact person name" id="company_contact_person_1" maxlength="250" name="company_contact_person_1" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_contact_person_1" data-valmsg-replace="true"></span> </div> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_contact_person_designation_1">Designation <span class="text-danger">*</span></label> <input class="form-control shadow-none rounded-0" data-val="true" data-val-required="Please enter primary contact person designation" id="company_contact_person_designation_1" maxlength="250" name="company_contact_person_designation_1" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_contact_person_designation_1" data-valmsg-replace="true"></span> </div> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_contact_person_phone_1">Phone <span class="text-danger">*</span></label> <input class="form-control shadow-none rounded-0" data-val="true" data-val-required="Please enter primary contact person phone" id="company_contact_person_phone_1" maxlength="250" name="company_contact_person_phone_1" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_contact_person_phone_1" data-valmsg-replace="true"></span> </div> </div> <div class="col-12 col-md-6"> <div class="form-floatings"> <label class="form-label fw-medium" for="company_contact_person_email_1">Email <span class="text-danger">*</span></label> <small class="text-muted"><i>(ex. email@example.com)</i></small> <input class="form-control shadow-none rounded-0" data-val="true" data-val-regex="Please enter a valid email address" data-val-regex-pattern="^[^\s@]+@[^\s@]+\.[^\s@]+$" data-val-required="Please enter primary contact person email" id="company_contact_person_email_1" maxlength="250" name="company_contact_person_email_1" required="required" type="text" value="" /> <span class="field-validation-valid error" data-valmsg-for="company_contact_person_email_1" data-valmsg-replace="true"></span> </div> </div> </div> <div class="text-center"> <button type="submit" class="btn btn-primary rounded-0 px-4">Submit</button> </div> </div> </section> </div> </form> </div> </div> </div> </div> </div> <div class="container px-xl-5 px-lg-4 p-md-0 mt-3"> <div class="row"> <div class="col-xl-8 col-lg-10 mx-auto"> <div class="text-center pt-3 bg-dark bg-opacity-50 text-white py-4"> &copy; 2024 Tata Memorial Centre. All rights reserved. </div> </div> </div> </div> <script src="/src/dhsl-form/assets/js/app.js"></script> <!-- Form Validate init js --> <script src="/Areas/Webadmin/assets/libs/parsleyjs/parsley.min.js"></script> <script src="/Areas/webadmin/assets/js/pages/form-validation.init.js"></script> <script src="/src/js/multiselect.js"></script> <script> $(document).ready(function () { $(".sd-CustomSelect").multipleSelect({ selectAll: false, onOptgroupClick: function (view) { $(view).parents("label").addClass("selected-optgroup"); } }); // chnage event of multi_category_id $("input[name='multi_category_id']").change(function () { // if any selected then remove required if ((this).value != "" && (this).value != undefined) { $("input[name='multi_category_id']").removeAttr("required"); $('#err_multi_category_id').text(''); } else { $("input[name='multi_category_id']").attr("required", true); $('#err_multi_category_id').text('Please select at least one category'); } }) $('form').on('submit', function (e) { // Get an array of all checked checkbox values var _arrCategory = $("input[name='multi_category_id']:checked").map(function () { return $(this).val(); }).get(); if (_arrCategory.length > 0) { $('.multi_category_id').removeAttr('required'); $('#err_multi_category_id').text(''); } else { $('.multi_category_id').attr('required', true); $('#err_multi_category_id').text('Please select at least one category'); e.preventDefault(); } }); }); </script> </body> </html>

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