First Name (given name)
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Last Name (surname/family name)
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Do you have a health insurance card (kenko hokensyo) ?
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Did you contact with a Covid-positive person within two weeks?
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Do you have any medical condition?
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Are you allergic to any medications?
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If you say "Yes" in the question above, describe about the medicine.
Which method do you want to get an inspection for COVID-19?
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How do you want to pay for medical expenses?
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Please feel free to write down anything you want.