Patient with Fever

Please Use PHONE first if you need to see today or urgent.
*indicates a required field.

First Name (given name) *
Last Name (surname/family name) *
Date of Birth *
Year - Month - Date
 -  - 
Age *
Gender
Phone No. *
- -
e-mail *

(確認用)
confirm e-mail
Address[Postal Code]
-
If you click the button, Japanese will be appeared.
Address *
Do you have a health insurance card (kenko hokensyo) ? *



Desired Date *
Year - Month - Date
 -  - 
Desired Time *
multiple answers possible

What is your symptoms? *

Did you contact with a Covid-positive person within two weeks? *
Do you have any medical condition? *

Do you smoke? *
Are you pregnant? *
Are you allergic to any medications? *
If you say "Yes" in the question above, describe about the medicine.
Which method do you want to get an inspection for COVID-19? *



How do you want to pay for medical expenses? *
Please feel free to write down anything you want.
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