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[]
[]
["訪問診療申込書"]
[]
[]
[]
["いしが在宅ケアクリニック　宛",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX　059-336-2405"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Email　ishiga.homecare24@gmail.com"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL 059-336-2404"]
[]
[]
["下記の項目についてご記入いただきお送り下さい。"]
["送信の前にお電話をいただけますと幸いです。受信・確認後、担当者よりお電話させていただきます。"]
[]
["発信日",null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,"日"]
[]
["紹介元医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　"]
[]
[]
["申込担当者の\n所属・名前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL："]
[]
[]
[]
["フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別"]
[]
["患者様氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"生年　　月日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　年　　　　　月　　　　　日生　　　　歳"]
[]
["訪問先住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL",null,null,null,"①",null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,"）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"②",null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,"）"]
[]
["医療保険の種類",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　割負担"]
[]
[]
[]
["介護保険",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要支援：",null,null,null,null,null,null,"要介護：",null,null,null,null,null,null,"　　　　割負担"]
[]
[null,null,null,null,null,null,null,null,null,null,"居宅事業所：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者：",null,null,null,null,null,null,null,null,null,null,"TEL："]
[]
["訪問看護",null,null,null,null,null,null,null,null,null,"事業所："]
[]
[]
["訪問開始時期"]
[]
[]
["病名及び既往歴"]
[]
[]
[]
["現在受けている\n医療行為",null,null,null,null,null,null,null,null,null,"　　　　　　　　　　　　　"]
[]
[]
[]
["依頼目的\n日常生活動作など"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["本人・家族の意向",null,null,null,null,null,null,null,null,null,"本人："]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"家族："]
[]
[]
["家族構成\n生活状況",null,null,null,null,null,null,null,null,null,"キーパーソン：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主介護者："]
[]
[]
[]
[]
[]
["経済状態"]
[]
[]
["特記事項　　　　　　　　　（伝えておきたいこと　　　　　　　　　困っていることなど）"]

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