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Registrant First Name *
Registrant Last Name *
Registrant Address *
Street Address
Address Line 2
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I am registering for *
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Registrant Pic *
Person to be register Name *
Person to be registered PIC *
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Person to be register Address *
Street Address
Address Line 2
City
State / Province / Region

Zip / Postal Code
Country
Email *
Confirm Email *
Please select all services you will need *
Accommodation
Social integration into a bajan family
Group Living
Group activates
Health monitoring
Activities for seniors
Medical care
Independent Living
This will help ous to create your senior care package
Would you be using our EMR system *
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Electronic Medical Record
How long will you be staying with us *
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Who will Be Paying *
Payment Method
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Any Request
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Home Phone #
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Password *
confirm Password *
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No Medical Information Required
Access to this restricted area will be granted after your meeting and payment have been received.
Medical Information Required
By registering as a client you will need to enter the registered person's medical information in our EMR (Electronic Medical Records) This will allowed doctors in Barbados to understand their medical history and keep an updated record. Access to this restricted area will be granted after your meeting and payment have been received.
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