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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,{"$f":"IFERROR(VLOOKUP(P4,X5:AB13,3,FALSE),\"\")","v":1370702233},null,null,null,null,null,null,"≪各事業所の提供エリアの目安≫　※エリア外もご相談ください"]
["貴事業所名　",null,null,null,null,null,null,null,null,null,null,null,null,"当社事業所名  ",null,"ラックすみだ",null,null,null,null,null,null,null,"事業所を選択してください",null,0]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB13,4,FALSE),\"\")","v":"03-5655-7503"},null,null,null,null,null,null,null,"ラックすみだ","墨田区、江戸川区、江東区、葛飾区",1370702233,"03-5655-7503","03-5655-7523"]
["ＦＡＸ",null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ",null,{"$f":"IFERROR(VLOOKUP(P4,X5:AB13,5,FALSE),\"\")","v":"03-5655-7523"}]
["ご担当者様　",null,null,null,null,null,null,null,"（貸与）",null,null,null,null,"担当者"]
[]
["被　保　険　者",null,null,null,null,null,null,null,null,null,null,null,null,"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,null,"続柄"]
["氏　名",null,null,null,null,null,null,null,null,null,null,"男 ・ 女"]
["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,"　明 ・ 大 ・ 昭 　　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,"＜その他の情報＞"]
["被保険者番号",null,null," "]
["減額措置",null,null,"無 ・ 有（　　　　　　　　　　　　　　） "]
["利用者負担の割合",null,null,"１割　・　２割・　３割　・　生活保護"]
["負担者番号"]
["受給者番号"]
["認定結果",null,null,"申請中　・　要支援　（　　　　　）・　要介護　（　　　　　）"]
["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 "]
["サービスの種類",null,null,"□　車いす　（　自躁　・　介助　・　その他　）　　　　　□　車いす付属品　　　　　　　　　　　　　　　　　　　　　　　　　   □　特殊寝台\n□　特殊寝台付属品　（　マットレス　・　介助バー　・　サイドレール　　\n　　　　　　　　　　　　キャスター　・　オーバーテーブル　・　その他）　　　　　　　　　　　　　　　　　　　　　　　□　床ずれ防止用具　　□　体位変換器　　□　簡易手すり　□　簡易スロープ　　　　　　□　歩行器　　　　　　□　歩行補助杖　　□　徘徊感知器　□　移動用リフト　　　　　　　　"]
["　現在の病状　　　商品の詳細など"]
["主治医\n※記入しなくても\n構いません",null,null,"　　　　　　　　　　　病院 ・ 医院 ・ クリニック　　　　　　　　　　Ｄｒ"]
["納品・引上・点検の希望日",null,null,"　　　月　　　日（　ＡＭ　・　ＰＭ　）　　　時　　　分　"]
[]
[]
["備考欄"]
["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"]