足のクリニック表参道

※こちらは問診になります。予約ではございませんのでご注意ください。
予約を取る際はHP上の予約システムよりお取りください。

For Patients Who Cannot Read Japanese:
Explanations for each item are provided below.
Please refer to them when filling out the medical questionnaire.

◇Do you know your patient ID number?→ Yes→Enter your patient ID number
◇If this is your first visit → No→Please select your expected visit date.

●来院予定日→expected visit date.
●氏名→name　※Required infomation.
●性別→gender ※Required infomation.
●生年月日→birthday ※Required infomation.
●電話番号→telephone number ※Required infomation.
●固定電話→landline phone
●緊急連絡先→energency contact 〈Relationship〉
●E-mail→email address
●郵便番号→post code ※Required infomation.
●住所→address ※Required infomation.