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[null,null,null,null,null,null,"＜ 新 規 依 頼 書 ＞　",null,null,null,null,null,null,null,"ご依頼日："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,"年",null,"月",null,"日",null,"※ご依頼の際は手渡しまたはFAX等でお送りください。"]
["貴事業所番号",null,null,null,null,null,null,null,null,null,null,null,null,"当社事業所番号",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB15,3,FALSE),\"\")","v":""},null,null,null,null,null,null,"≪各事業所の訪問エリアの目安≫　※エリア外もご相談ください"]
["貴事業所名　",null,null,null,null,null,null,null,null,null,null,null,null,"当社事業所名  ",null,"事業所を選択してください",null,null,null,null,null,null,null,"事業所を選択してください",null,0]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB15,4,FALSE),\"\")","v":""},null,null,null,null,null,null,"墨田区","ラックすみだ","墨田区京島、東向島（2、6丁目）、押上、向島など",1370700138,"03-5655-7500","03-5655-7520"]
["ＦＡＸ",null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB15,5,FALSE),\"\")","v":""},null,null,null,null,null,null,null,"ラック鐘ヶ淵","墨田区墨田、堤通、東向島（3～5丁目）など",1370703116,"03-5630-2236","03-5630-2237"]
["ご担当者様　",null,null,null,null,null,null,null,null,null,null,null,null,"担当者",null,null,null,null,null,null,null,null,null,"ラック立花","墨田区立花、文花など",1370703207,"03-5631-7151","03-5631-7153"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ラック厩橋","墨田区本所、東駒形、吾妻橋、亀沢、石原、横網、緑、両国、立川、菊川、千歳など",1370702407,"03-5969-8524","03-5969-8541"]
["被　保　険　者",null,null,null,null,null,null,null,null,null,null,null,null,"介　護　者",null,null,null,null,null,null,null,null,"江戸川区","ラック平井","江戸川区平井、小松川など",1372304707,"03-3682-4441","03-3682-4443"]
["フリガナ",null,null,null,null,null,null,null,null,null,null,"性別",null,null,null,null,null,null,null,"続柄",null,null,null,"ラック小岩","江戸川区南小岩、東小岩、西小岩、北小岩など",1372304822,"03-5612-1431","03-5612-1484"]
["氏　名",null,null,null,null,null,null,null,null,null,null,"男 ・ 女",null,null,null,null,null,null,null,null,null,null,null,"ラック葛西","江戸川区中葛西、東葛西、北葛西、宇喜田など",1372304061,"03-5674-7151","03-5674-6206"]
["住　所",null,null,"〒",null,null,null,null,null,null,null,null,null,"〒",null,null,null,null,null,null,null,null,"江東区","ラック亀戸","江東区亀戸など",1370803643,"03-3681-5031","03-3681-5167"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ラック大島","江東区大島、東砂、南砂、北砂など",1370805721,"03-5875-5327","03-5875-5329"]
["電話番号",null,null,"―　　　　　　　―",null,null,null,null,null,null,null,null,null,"ー　　　　　　―",null,null,null,null,null,null,null,null,"葛飾区","ラック金町","葛飾区金町、東金町、水元、新宿など",1372203941,"03-6689-0184","03-5648-2567"]
["生年月日",null,null,"　明 ・ 大 ・ 昭 ・ 平　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,"＜その他の情報＞\n\n"]
["被保険者番号"]
["認定結果",null,null,"　 申請中 ・ 要介護 １ ・ ２ ・ ３ ・ ４ ・ ５"]
[null,null,null,"　 要支援  １ ・ ２ ・ 事業対象者"]
["認定有効期間",null,null,"  平成 ・ 令和 　　　年　　　月　　　日　　"]
[null,null,null,"～　平成 ・ 令和　　　年　　　月　　　日 "]
["減額措置",null,null,"無 ・ 有（　　　　　　　　　　　　　　） "]
["負担割合",null,null,"１割　・　２割・　３割　・　生活保護"]
["援助の方向性　　　目標"]
["介護状況　　　　　　　　現在の病状・他"]
["希望サービス",null,null,"訪問介護（ 身体介護 ・ 生活援助 ）・　総合事業  ・ その他（　　　　　　　）　　　　　　　　　　　"]
["感染症",null,null,"無 ・ 有（　　　　　　　／注意事項　　　　　　　　　　　　　　　　　） "]
["利用希望日　　　　　時間",null,null,"サービス開始日　令和　　年　　　月　　　日"]
[]
["要望ケア内容"]
["当社記入欄",null,null,"事前訪問　　　/",null,null,null,null,"初回訪問　　　/",null,null,null,null,null,"株式会社　ラックコーポレーション\n2019.05"]