{"id":6523,"date":"2026-03-16T05:26:35","date_gmt":"2026-03-16T05:26:35","guid":{"rendered":"https:\/\/klipworld.com.my\/lfm\/?page_id=6523"},"modified":"2026-03-16T06:34:50","modified_gmt":"2026-03-16T06:34:50","slug":"loan-application","status":"publish","type":"page","link":"http:\/\/klipworld.com.my\/lfm\/loan-application\/","title":{"rendered":"Patient Loan Application"},"content":{"rendered":"        <div class=\"lfm-form-container\">\n            <form id=\"lfm-loan-application-form\" class=\"lfm-form\" method=\"post\" enctype=\"multipart\/form-data\">\n                <div class=\"form-header\">\n                    <h2>Application for Loan of CPAP\/BPAP\/OXYGEN CONCENTRATOR\/PORTABLE OXYGEN<\/h2>\n                    <p class=\"form-instructions\">Please complete all required fields marked with <span class=\"required\">*<\/span><\/p>\n                <\/div>\n                \n                <!-- Patient Information -->\n                <fieldset class=\"form-section\">\n                    <legend>Patient Information<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"patient_name\">Name of Patient <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"patient_name\" name=\"patient_name\" required \n                                   placeholder=\"Full name as per IC\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"patient_ic\">I.C. Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"patient_ic\" name=\"patient_ic\" \n                                   pattern=\"[0-9]{6}-[0-9]{2}-[0-9]{4}\" \n                                   placeholder=\"000000-00-0000\" \n                                   maxlength=\"14\"\n                                   required class=\"lfm-input ic-mask\">\n                            <small>Format: 000000-00-0000<\/small>\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"patient_address\">Address <span class=\"required\">*<\/span><\/label>\n                        <textarea id=\"patient_address\" name=\"patient_address\" rows=\"3\" required \n                                  class=\"lfm-input\" placeholder=\"Complete address\"><\/textarea>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"patient_tel\">Tel No. <span class=\"required\">*<\/span><\/label>\n                            <input type=\"tel\" id=\"patient_tel\" name=\"patient_tel\" required \n                                   placeholder=\"012-3456789\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"patient_email\">Email Address<\/label>\n                            <input type=\"email\" id=\"patient_email\" name=\"patient_email\" \n                                   placeholder=\"patient@example.com\" class=\"lfm-input\">\n                            <small>For confirmation email<\/small>\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"patient_signature_date\">Date <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"patient_signature_date\" name=\"patient_signature_date\" \n                                   required class=\"lfm-input\" value=\"2026-08-01\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Guardian Information -->\n                <fieldset class=\"form-section\">\n                    <legend>Guardian Information <small>(For Paediatric Patient)<\/small><\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"guardian_name\">Name of Father\/Mother\/Guardian<\/label>\n                            <input type=\"text\" id=\"guardian_name\" name=\"guardian_name\" \n                                   placeholder=\"Full name\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"guardian_ic\">I.C. Number<\/label>\n                            <input type=\"text\" id=\"guardian_ic\" name=\"guardian_ic\" \n                                   pattern=\"[0-9]{6}-[0-9]{2}-[0-9]{4}\" \n                                   placeholder=\"000000-00-0000\" \n                                   maxlength=\"14\" class=\"lfm-input ic-mask\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"guardian_signature_date\">Date<\/label>\n                            <input type=\"date\" id=\"guardian_signature_date\" name=\"guardian_signature_date\" \n                                   class=\"lfm-input\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Emergency Contact -->\n                <fieldset class=\"form-section\">\n                    <legend>Emergency Contact Details<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"emergency_name\">Name <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"emergency_name\" name=\"emergency_name\" required \n                                   placeholder=\"Emergency contact person\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"emergency_tel\">Tel No. <span class=\"required\">*<\/span><\/label>\n                            <input type=\"tel\" id=\"emergency_tel\" name=\"emergency_tel\" required \n                                   placeholder=\"012-3456789\" class=\"lfm-input\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"emergency_relation\">Relationship to Patient<\/label>\n                        <input type=\"text\" id=\"emergency_relation\" name=\"emergency_relation\" \n                               placeholder=\"e.g., Spouse, Child, Parent\" class=\"lfm-input\">\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Witness -->\n                <fieldset class=\"form-section\">\n                    <legend>Witness<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"witness_name\">Name <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"witness_name\" name=\"witness_name\" required \n                                   placeholder=\"Full name of witness\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"witness_ic\">I.C. Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"witness_ic\" name=\"witness_ic\" \n                                   pattern=\"[0-9]{6}-[0-9]{2}-[0-9]{4}\" \n                                   placeholder=\"000000-00-0000\" \n                                   maxlength=\"14\" required class=\"lfm-input ic-mask\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"witness_signature_date\">Date <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"witness_signature_date\" name=\"witness_signature_date\" \n                                   required class=\"lfm-input\" value=\"2026-08-01\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Terms and Conditions -->\n                <fieldset class=\"form-section\">\n                    <legend>Terms and Conditions<\/legend>\n                    \n                    <div class=\"terms-box\">\n                        <h4>Terms and Conditions of Loan<\/h4>\n                        <ol>\n                            <li>The machine is on loan to the patient. It remains the property of the Foundation.<\/li>\n                            <li>The full set machine must be returned to Lung Foundation of Malaysia when the patient does not require the use of the machine and must be in good condition upon returning.<\/li>\n                            <li>Parents \/ Guardians \/ Patient is responsible to take good care of the machine and to pay for the cost of repairing the machine while the machine is in the user's possession.<\/li>\n                            <li>The Lung Foundation of Malaysia reserves the right to take back the machine at any time if the rules were violated and\/or the patient does not require the use of the machine.<\/li>\n                        <\/ol>\n                        \n                        <h4>Patient Care Instructions<\/h4>\n                        <ul>\n                            <li>Wash hands before handling the machine<\/li>\n                            <li>Machine must be placed away from any inflammatory items<\/li>\n                            <li>Clean outside machine with clean water daily and wipe dry<\/li>\n                            <li>Clean tubing and sponge filter with clean water<\/li>\n                            <li>Change water in humidifier daily with cold boiled water<\/li>\n                            <li>Filter must be checked weekly and changed if discolored<\/li>\n                            <li>Machine must be serviced every 6 months<\/li>\n                        <\/ul>\n                    <\/div>\n                    \n                    <div class=\"form-group checkbox-group\">\n                        <label>\n                            <input type=\"checkbox\" name=\"agree_terms\" value=\"1\" required>\n                            I have read and agree to the terms and conditions <span class=\"required\">*<\/span>\n                        <\/label>\n                    <\/div>\n                    \n                    <div class=\"form-group checkbox-group\">\n                        <label>\n                            <input type=\"checkbox\" name=\"confirm_instructions\" value=\"1\" required>\n                            I confirm that I have been explained the use of the machine and understand the care instructions <span class=\"required\">*<\/span>\n                        <\/label>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Acknowledgement -->\n                <fieldset class=\"form-section\">\n                    <legend>Acknowledgement<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"acknowledgement_name\">Name of Patient\/Father\/Mother\/Guardian <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"acknowledgement_name\" name=\"acknowledgement_name\" required \n                                   class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"acknowledgement_date\">Date <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"acknowledgement_date\" name=\"acknowledgement_date\" \n                                   required class=\"lfm-input\" value=\"2026-08-01\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Guarantor -->\n                <fieldset class=\"form-section\">\n                    <legend>Guarantor Information<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"guarantor_name\">Name of Guarantor <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"guarantor_name\" name=\"guarantor_name\" required \n                                   placeholder=\"Full name\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"guarantor_ic\">I.C. Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"guarantor_ic\" name=\"guarantor_ic\" \n                                   pattern=\"[0-9]{6}-[0-9]{2}-[0-9]{4}\" \n                                   placeholder=\"000000-00-0000\" \n                                   maxlength=\"14\" required class=\"lfm-input ic-mask\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"guarantor_phone\">Phone Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"tel\" id=\"guarantor_phone\" name=\"guarantor_phone\" required \n                                   placeholder=\"012-3456789\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"guarantor_date\">Date <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"guarantor_date\" name=\"guarantor_date\" \n                                   required class=\"lfm-input\" value=\"2026-08-01\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Form Actions -->\n                <div class=\"form-actions\">\n                    <button type=\"submit\" class=\"submit-button\">\n                        <span class=\"button-text\">Submit Application<\/span>\n                        <span class=\"loading-spinner\" style=\"display: none;\">Submitting...<\/span>\n                    <\/button>\n                <\/div>\n                \n                <div id=\"form-message\" class=\"form-message\"><\/div>\n            <\/form>\n        <\/div>\n        \r\n\r\n&nbsp;\r\n\r\n<!-- \/wp:post-content -->","protected":false},"excerpt":{"rendered":"<p>&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-6523","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages\/6523","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/comments?post=6523"}],"version-history":[{"count":2,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages\/6523\/revisions"}],"predecessor-version":[{"id":6557,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages\/6523\/revisions\/6557"}],"wp:attachment":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/media?parent=6523"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}