Long-Term and Short-Term Senior Residence - Senior Residence by Dhevan Dara

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Name *

Surname *

Date of Birth *

Nationality *

Email Address *

No. of Guests *

Estimated Arrival Date *

Preferred Type of Food

Your Interest

Type of Accommodation *

1 Bedroom Pool villa 2 Bedroom Pool villa

Food Package *

Breakfast Only Two Meals Per Day Three Meals Per Day

Nursing Care Program *

Basic Nursing Program Focused Nursing Program Full Nursing Program

Duration of Intended Stay *

1-3 Months 4-6 Months 7 Months and Over

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Do you have any physical impairments?

Have you ever visited Thailand? If so, please specify the approximate period.

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Please describe your health conditions.

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