<%@ Language=VBScript %> Kurashiki Central Hospital Website- For Patients : General inruiry form
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General inquiry form

For new patients:

Fill out the relevant information below.

Family name
mark_mandatory field
Given names
mark_mandatory field
Date of birth
(yyyy/mm/dd)
Sex
Male Female
Address

Prefecture    Postcode
Telephone number
mark_mandatory field
Native/Other Language
Native
  
Other language(s)
  
Mail
mark_mandatory field

Any questions can be directed to this email address.

Do you wish to see a doctor at this hospital? Please enter any symptoms or requests you may have.

 

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