Follow up Consultation

Name ※
Gender ※	MaleFemaleOther
Patient ID (Number)
Request of appointment, Date and Time Closed：Sat・Sun・National Holidays In case of emergency, you can call us anytime.	First：～ Second：～ Third：～
Purpose of visiting	Doctor ConsultationHealth Check upVaccination
Health Insurance　※	Having Japanese Health InsuranceNo Japanese Health Insurance. （Having International Health Insurance or tourist short-stay visitor）
Email※
Remarks