Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

年

月

日

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

観心医院嘉義医院観心薬局

関新健康診断センター

佳藝診所

住所: 黎明東路2-1-2号150号

住所: 豊原区豊市路2段388号

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