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First Name
*
Last Name
*
Date of Birth
*
Phone Number
*
Gender
*
Select the gender
Male
Female
Other
Monthly Payment
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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
*
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