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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 example@example.com
Birthday
Telephone Number 09012345678
Address
Do you have any chronic illness?
The name of illness :
Are you taking any medicine?
The name of medicine :
Do you have any allergies?
Allergy object :
What are your symptoms?

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名字
出生年月日
住所
電話號碼 09012345678
郵件地址 example@example.com
年齡
您有任何正在治療中的疾病嗎?
病名 :
您有任何正在服用中的藥物?
薬名 :
您有任何藥物或食物過敏反應嗎?
對象 :
請告知您頭髮的症狀
Message

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