CONSULTATION SHEET
Name
Sex
Male
Female
Email
Tel/Cell
Date of birth
Postal code
Address
Occupation
Office worker
Student
Self-employed
Homemaker
Other
Recommended By
Friend
Internet
Advertisment
Others
If you chose "friend", please enter your friend's name.
Please mark below where you feel the symptom
When did the symptom start?
Do you have any idea what might be cause?
What makes it worse?
Have you ever had a major illness or injury?
Do you have any questions？
Preferred reservation date?
（Except on Tuesday and Wednesday:10:00-20:00)
① Month. DAY. Time .
② Month. DAY. Time .
We will reply to e-mail later.
Please let me arrange my schedule.
※問診票に記入し送信が完了した際に記入した個人情報を含む情報を利用事業者及びWEB問診機能を提供する株式会社ケアクルが取得することに同意したものとみなされます。
ケアクルにおける個人情報の取り扱いについては、
プライバシーポリシー
をご確認ください。
※It will not be sent until you press the button to complete the input on the confirmation page.