VEGAN EXAMS

Name※
Gender※	Male Female Other
Date of birth※
Place of staying※
Request of appointment, Date and Time Closed： Sat・Sun・NationalHolidays In case of emergency, you can call usanytime.	第一希望：　～第二希望：　～第三希望：　～
Purpose	Doctor's Consultation Need medicines which run out ot you do not bring.
Email（半角）※
Phone number
For under 15 years old Please put your body weight.	Kg
Details of symptoms or name and dozges of medicines which you need.　※