| ※Symptoms |
|
| Please let us know a number of preferred days that you would like to have first medical examination. |
※The first choice
The second choice
The third choice
|
| ※Name |
|
| ※Age |
|
| ※Sex |
|
| ※Email Address |
例example@example.com |
| ※Telephone Number |
例09012345678 |
| Address |
|
| Do you have any chronic illness? |
The name of illness :
|
| Are you taking any medicine? |
The name of medicine :
|
