Custom Registration Form in WordPress

We need a form where a user registers with:
1. Title
2. First name
3. Last Name
4. Date of Bith
5. Gender
6. Email Address
7. Password
8. Drop down on few things to choose from (We will provide you with this).
9. (TICKY PART) - User to start typing in the name of the hospital and while they are typing, the results should start appearing as a autocomplete. Hospital name, address and postcode will come from database file we have (CSV Format). So they can only select from our list. If the map can be shown, it will be a bonus (Optional).
10. From the autocomplete above, once they have clicked on the hospital they require, it should fill in the rest of the field i.e, hospital name, address and postcode.
11. 2 Yes or no checkbox
12. Drop down on few things to choose from (We will provide you with this).
13. Very important, a checkbox to agree to the terms and condition.
14. Thank you message.
15. A user account is only creation user we have certified the information from this above form.

This form is for data collection only.

For your ease we can provide you process from our competitor, we have a screenshot of the whole procedure. We can skype if needed.