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First Name *

Last Name *

Date of Birth *

Phone Number *

Gender * Select the gender Male Female Other

Monthly Payment *

Pension *

Room No *

Diagnose 1 *

Diagnose 2

Diagnose 3

Immobility * Select immobility value Yes No

Dependency * Select dependency value Low Medium High

Date of Arrival: *

Date of Departure

Contact Name *

Contact Last Name *

Contact Phone Number *