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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。"]
["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,{"$f":"IFERROR(VLOOKUP(P4,X5:AB13,3,FALSE),\"\")","v":1360790032},null,null,null,null,null,null,"≪各事業所の訪問エリアの目安≫　※エリア外もご相談ください"]
["貴事業所名　",null,null,null,null,null,null,null,null,null,null,null,null,"当社事業所名  ",null,"ラック訪問看護ステーションすみだ",null,null,null,null,null,null,null,"事業所を選択してください",null,0]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB13,4,FALSE),\"\")","v":"03-5655-7505"},null,null,null,null,null,null,null,"ラック訪問看護ステーションすみだ","墨田区墨田、堤通、東向島、八広、東墨田、京島、立花\n文花、業平、向島、横川、東駒形",1360790032,"03-5655-7505","03-5655-7525","kango@lac-corp.com"]
["ＦＡＸ",null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB13,5,FALSE),\"\")","v":"03-5655-7525"}]
["メールアドレス",null,null,null,null,null,null,null,null,null,null,null,null,"メールアドレス",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AC13,6,FALSE),\"\")","v":"kango@lac-corp.com"}]
["ご担当者様　",null,null,null,null,null,null,null,null,null,null,null,null,"担当者"]
[]
["被　保　険　者",null,null,null,null,null,null,null,null,null,null,null,null,"キーパーソン　介護者"]
["フリガナ",null,null,null,null,null,null,null,null,null,null,"性別",null,"　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,"続柄"]
["氏　名",null,null,null,null,null,null,null,null,null,null,"男 ・ 女",null,"　　　　　　　　　　　　　"]
["住　所",null,null,"〒",null,null,null,null,null,null,null,null,null,"〒"]
["電話番号",null,null,"―　　　　　　　―",null,null,null,null,null,null,null,null,null,"ー　　　　　　―"]
["生年月日",null,null," Ｍ ・ Ｔ ・ Ｓ ・ Ｈ ・ R　  　年　 　月　 　日（　 　歳）"]
["訪問形態",null,null,"□　介護保険　　□医療保険",null,null,null,null,null,null,"要介護度",null,null,"要介護□１　□２　□３　□４　□５"]
["※公費　□生保　□５１　□その他（　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"要支援□１　□２　□申請中　□未申請"]
["現在の状態",null,null,"病名　　　："]
[null,null,null,"感染症　□あり　□なし"]
[null,null,null,"認知症（□あり　□なし）　　　ADL（□歩ける　□歩けない　□車いす）"]
[null,null,null,"症状　・　ADL　："]
[]
[]
[]
[]
["介護環境"]
["入退院別",null,null,"□在宅　□入院中（退院予定 　/ 　）（退院時カンファレンス予定 　/ 　）"]
["主治医",null,null,"病院名　　　　　",null,null,null,null,null,"診療科目",null,null,null,null,"担当医　　　　　先生"]
[null,null,null,"住所　〒"]
[null,null,null,"電話番号  "]
[null,null,null,"主治医の承諾　　　有　（指示書の発行　済　・　未）"]
["備考欄　　　　　　　（訪問希望曜日や　　　訪問がダメな曜日）　"]
[]
[]
["当社記入欄",null,null,"事前訪問　　　/",null,null,null,null,"初回訪問　　　/",null,null,null,null,"ケアマネージャー同席　□あり　□なし"]
[]
[null,null,null,"男性看護師　OK",null,null,null,null,null,null,null,null,"株式会社　ラックコーポレーション\n2019.05"]