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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 例example@example.com
Birthday
Telephone Number 例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?